See other bills
under the
same topic
PRIOR PRINTER'S NOS. 1131, 1138, 1237,
1330, 1946
PRINTER'S NO. 2648
THE GENERAL ASSEMBLY OF PENNSYLVANIA
HOUSE BILL
No.
934
Session of
2015
INTRODUCED BY CHRISTIANA, V. BROWN, MILLARD, HELM, KOTIK,
MUSTIO, DRISCOLL, McNEILL, LONGIETTI, COHEN, QUIGLEY,
A. HARRIS, ORTITAY, MARSHALL, SIMMONS, SCHREIBER, GRELL,
SAYLOR, STEPHENS, GROVE, MURT, WATSON, GABLER, KAUFER,
GIBBONS, JOZWIAK, M. DALEY AND DAVIS, APRIL 8, 2015
AMENDMENTS TO SENATE AMENDMENTS, HOUSE OF REPRESENTATIVES,
DECEMBER 9, 2015
AN ACT
Amending the act of June 13, 1967 (P.L.31, No.21), entitled "An
act to consolidate, editorially revise, and codify the public
welfare laws of the Commonwealth," in public assistance,
providing for the establishment of KEYS; in children and
youth, further providing for provider submissions; in
departmental powers and duties as to supervision, further
providing for definitions; in departmental powers and duties
as to licensing, further providing for definitions, for fees
and for provisional license; repealing provisions relating to
registration provisions; and, in family finding and kinship
care, further providing for definitions, for kinship care
program and for permanent legal custodianship subsidy and
reimbursement; abrogating a regulation; and making editorial
changes.
AMENDING THE ACT OF JUNE 13, 1967 (P.L.31, NO.21), ENTITLED "AN
ACT TO CONSOLIDATE, EDITORIALLY REVISE, AND CODIFY THE PUBLIC
WELFARE LAWS OF THE COMMONWEALTH," IN PUBLIC ASSISTANCE,
PROVIDING FOR THE ESTABLISHMENT OF KEYS, FOR COPAYMENTS FOR
SUBSIDIZED CHILD CARE, FOR MEDICAL ASSISTANCE PAYMENTS FOR
INSTITUTIONAL CARE, FOR OTHER MEDICAL ASSISTANCE PAYMENTS,
FOR MILEAGE REIMBURSEMENT AND PARATRANSIT SERVICES FOR
INDIVIDUALS RECEIVING METHADONE TREATMENT AND FOR OTHER
COMPUTATIONS AFFECTING COUNTIES; PROVIDING FOR CHILDREN'S
HEALTH CARE; IN CHILDREN AND YOUTH, FURTHER PROVIDING FOR
PAYMENTS TO COUNTIES FOR SERVICES TO CHILDREN, FOR PROVIDER
SUBMISSIONS AND FOR LIMITS ON REIMBURSEMENTS TO COUNTIES;
REPEALING PROVISIONS RELATING TO MEDICAID MANAGED CARE
ORGANIZATION ASSESSMENTS; IN STATEWIDE QUALITY CARE
ASSESSMENT, FURTHER PROVIDING FOR DEFINITIONS, FOR
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IMPLEMENTATION, FOR RESTRICTED ACCOUNT AND FOR EXPIRATION OF
ARTICLE; PROVIDING FOR MANAGED CARE ORGANIZATION ASSESSMENTS;
IN DEPARTMENTAL POWERS AND DUTIES AS TO SUPERVISION, FURTHER
PROVIDING FOR DEFINITIONS; IN DEPARTMENTAL POWERS AND DUTIES
AS TO LICENSING, FURTHER PROVIDING FOR DEFINITIONS, FOR FEES,
FOR PROVISIONAL LICENSE AND FOR VIOLATION AND PENALTY;
REPEALING PROVISIONS RELATING TO REGISTRATION PROVISIONS; IN
FAMILY FINDING AND KINSHIP CARE, FURTHER PROVIDING FOR
DEFINITIONS, FOR KINSHIP CARE PROGRAM AND FOR PERMANENT LEGAL
CUSTODIANSHIP SUBSIDY AND REIMBURSEMENT; ABROGATING
REGULATIONS; REPEALING PROVISIONS RELATING TO CHILDREN'S
HEALTH CARE IN THE ACT OF MAY 17, 1921 (P.L.682, NO.284),
KNOWN AS THE INSURANCE COMPANY LAW OF 1921; AND MAKING
EDITORIAL CHANGES.
The General Assembly of the Commonwealth of Pennsylvania
hereby enacts as follows:
Section 1. The act of June 13, 1967 (P.L.31, No.21), known
as the Public Welfare Code, is amended by adding a section to
read:
Section 405.1B. Establishment of KEYS.--(a) There is
established in the department a program which shall be known as
Keystone Education Yields Success (KEYS). KEYS shall be designed
to enable and to assist eligible individuals receiving TANF or
SNAP benefits to enroll in and pursue a certificate or degree
program within one of the Commonwealth's community colleges, a
career or technical school registered with the Department of
Education or university within the Pennsylvania State System of
Higher Education.
(b) A KEYS recipient shall be permitted to count vocational
education, including class time, clinicals, labs and study time
as set by the community college, university or school, toward
the recipient's core TANF work requirement for twenty-four
months.
(c) In accordance with KEYS and notwithstanding section
405.1, the following requirements shall apply:
(1) A recipient shall be enrolled in an approved degree
or certificate program that will assist the recipient in
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securing a job that pays a family-sustaining wage.
(2) A KEYS recipient may be granted extensions for six-
month periods to complete the certificate or degree program,
provided:
(i) the recipient is enrolled in a program that will
lead to a high-priority occupation, as defined in section
1301 of the act of December 18, 2001 (P.L.949, No.114),
known as the Workforce Development Act or a program the
community college has certified meets the same criteria
as a high-priority occupation;
(ii) The recipient has maintained a 2.0 grade point
average; and
(iii) the recipient has made satisfactory progress
toward completing the program, including, but not limited
to, completing all required developmental course work and
successfully completing an average of eight credits per
semester.
(d) A person who, without good cause, fails or refuses to
comply with the terms and conditions of the KEYS program shall
be terminated from the program.
(e) The department is authorized to promulgate regulations
to implement this section.
(f) The department shall implement this section in
conformity with Federal law.
(g) Nothing in this section creates or provides an
individual with an entitlement to services or benefits. Services
under this section shall only be available to individuals
enrolled in the KEYS program to the extent that funds are
available.
SECTION 2. SECTION 408.3 OF THE ACT, ADDED JUNE 30, 2011
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(P.L.89, NO.22), IS AMENDED TO READ:
SECTION 408.3. COPAYMENTS FOR SUBSIDIZED CHILD CARE.--(A)
NOTWITHSTANDING ANY OTHER PROVISION OF LAW OR DEPARTMENTAL
REGULATION, THE PARENT OR CARETAKER OF A CHILD ENROLLED IN
SUBSIDIZED CHILD CARE SHALL PAY A COPAYMENT FOR THE SUBSIDIZED
CHILD CARE BASED ON A PERCENTAGE OF THE FAMILY'S ANNUAL INCOME
AS SPECIFIED IN A COPAYMENT SCHEDULE ESTABLISHED BY THE
DEPARTMENT PURSUANT TO THIS SECTION.
(B) THE DEPARTMENT SHALL PUBLISH A NOTICE SETTING FORTH THE
COPAYMENT SCHEDULE IN THE PENNSYLVANIA BULLETIN.
(C) IN ESTABLISHING THE COPAYMENT AMOUNTS PURSUANT TO THIS
SECTION, ALL OF THE FOLLOWING SHALL APPLY:
(1) COPAYMENTS SHALL BE [BASED UPON] ON A SLIDING [INCOME]
SCALE BASED ON A PERCENTAGE OF THE FAMILY'S ANNUAL INCOME TAKING
INTO ACCOUNT FEDERAL POVERTY INCOME GUIDELINES. COPAYMENTS SHALL
BE UPDATED ANNUALLY.
(2) AT THE DEPARTMENT'S DISCRETION, COPAYMENTS MAY BE
IMPOSED:
(I) FOR EACH CHILD ENROLLED IN SUBSIDIZED CHILD CARE;
(II) BASED UPON FAMILY SIZE; OR
(III) IN ACCORDANCE WITH BOTH SUBPARAGRAPHS (I) AND (II).
(3) COPAYMENT AMOUNTS SHALL BE A MINIMUM OF FIVE DOLLARS
($5) PER WEEK AND [MAY] SHALL INCREASE IN INCREMENTAL AMOUNTS,
BASED ON A PERCENTAGE OF THE FAMILY'S ANNUAL INCOME, AS
DETERMINED BY THE DEPARTMENT [TAKING INTO ACCOUNT ANNUAL FAMILY
INCOME].
(3.1) AT INITIAL APPLICATION, THE FAMILY'S ANNUAL INCOME MAY
NOT EXCEED TWO HUNDRED PERCENT OF THE FEDERAL POVERTY INCOME
GUIDELINES.
(3.2) AFTER AN INITIAL DETERMINATION OR REDETERMINATION OF
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ELIGIBILITY, A CHILD SHALL CONTINUE TO BE ENROLLED IN SUBSIDIZED
CHILD CARE FOR TWELVE MONTHS REGARDLESS OF EITHER OF THE
FOLLOWING:
(I) A TEMPORARY CHANGE IN THE PARENT OR CARETAKER'S STATUS
AS WORKING OR ATTENDING A JOB TRAINING OR EDUCATIONAL PROGRAM.
(II) AN INCREASE IN THE FAMILY'S ANNUAL INCOME, IF THE
INCOME DOES NOT EXCEED EIGHTY-FIVE PERCENT OF THE STATE MEDIAN
INCOME FOR A FAMILY OF THE SAME SIZE.
(4) A FAMILY'S ANNUAL COPAYMENT UNDER EITHER PARAGRAPH (1)
OR (2) SHALL NOT EXCEED:
(I) EIGHT PERCENT OF THE FAMILY'S ANNUAL INCOME IF THE
FAMILY'S ANNUAL INCOME IS ONE HUNDRED PERCENT OF THE FEDERAL
POVERTY INCOME GUIDELINE OR LESS; [OR]
(II) ELEVEN PERCENT OF THE FAMILY'S ANNUAL INCOME IF THE
FAMILY'S ANNUAL INCOME EXCEEDS ONE HUNDRED PERCENT OF THE
FEDERAL POVERTY INCOME GUIDELINE[.], BUT IS NOT MORE THAN TWO
HUNDRED FIFTY PERCENT OF THE FEDERAL POVERTY INCOME GUIDELINE;
(III) THIRTEEN PERCENT OF THE FAMILY'S ANNUAL INCOME IF THE
FAMILY'S ANNUAL INCOME EXCEEDS TWO HUNDRED FIFTY PERCENT OF THE
FEDERAL POVERTY INCOME GUIDELINE, BUT IS NOT MORE THAN TWO
HUNDRED SEVENTY-FIVE PERCENT OF THE FEDERAL POVERTY INCOME
GUIDELINE; OR
(IV) BEGINNING AFTER JULY 1, 2017, FIFTEEN PERCENT OF THE
FAMILY'S ANNUAL INCOME IF THE FAMILY'S ANNUAL INCOME EXCEEDS TWO
HUNDRED SEVENTY-FIVE PERCENT OF THE FEDERAL POVERTY INCOME
GUIDELINE, BUT IS NOT MORE THAN THREE HUNDRED PERCENT OF THE
FEDERAL POVERTY INCOME GUIDELINE OR EIGHTY-FIVE PERCENT OF THE
STATE MEDIAN INCOME, WHICHEVER IS LOWER.
(5) NOTWITHSTANDING THIS SUBSECTION, BEGINNING WITH STATE
FISCAL YEAR 2012-2013, THE DEPARTMENT MAY ADJUST THE ANNUAL
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COPAYMENT PERCENTAGES SPECIFIED IN THIS SUBSECTION BY
PROMULGATION OF FINAL-OMITTED REGULATIONS UNDER SECTION 204 OF
THE ACT OF JULY 31, 1968 (P.L.769, NO.240), REFERRED TO AS THE
"COMMONWEALTH DOCUMENTS LAW."
(6) AT A REDETERMINATION, ON OR AFTER JULY 1, 2017, A FAMILY
THAT EXCEEDS THE MINIMUM WORK REQUIREMENTS AS A RESULT OF EACH
PARENT OR CARETAKER, OR IN THE CASE OF A SINGLE PARENT HOUSEHOLD
BY THE SOLE PARENT OR CARETAKER, PERFORMING ADDITIONAL WAGE-
EARNING HOURS SHALL HAVE A REDUCED COPAYMENT, NOT TO BE LESS
THAN THAT WHICH IS SET UNDER PARAGRAPH (3). THIS PARAGRAPH SHALL
APPLY ONLY TO A FAMILY THAT, AFTER MUTUALLY QUALIFYING FOR AND
RECEIVING SUBSIDIZED CHILD CARE AND BEING CURRENT ON THE
REQUIRED COPAYMENTS AS SET FORTH IN THIS SUBSECTION, INCREASES
ITS AVERAGE WORK WEEK AFTER THE EFFECTIVE DATE OF THIS PARAGRAPH
AND HAS INCREASED THE FAMILY'S ANNUAL INCOME AS A RESULT OF
WORKING ADDITIONAL WAGE-EARNING HOURS. THE DEDUCTION SHALL BE
APPLIED AS FOLLOWS:
(I) FOR AN AVERAGE WORK WEEK OF AT LEAST TWENTY-FIVE WAGE-
EARNING HOURS PER PARENT OR CARETAKER, THREE-QUARTERS OF ONE
PERCENT DEDUCTION FROM THE AMOUNT SET UNDER THIS SUBSECTION.
(II) FOR AN AVERAGE WORK WEEK OF AT LEAST THIRTY WAGE-
EARNING HOURS PER PARENT OR CARETAKER, A ONE AND ONE-HALF
PERCENT DEDUCTION FROM THE AMOUNT SET UNDER THIS SUBSECTION.
(III) FOR AN AVERAGE WORK WEEK OF AT LEAST THIRTY-FIVE WAGE-
EARNING HOURS PER PARENT OR CARETAKER, TWO AND ONE-QUARTER
PERCENT DEDUCTION FROM THE AMOUNT SET UNDER THIS SUBSECTION.
(IV) FOR AN AVERAGE WORK WEEK OF AT LEAST FORTY WAGE-EARNING
HOURS PER PARENT OR CARETAKER, A THREE PERCENT DEDUCTION FROM
THE AMOUNT SET UNDER THIS SUBSECTION.
(7) AT ITS REDETERMINATION OF ELIGIBILITY, A PARENT OR
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CARETAKER SHALL PROVIDE DOCUMENTATION OF ITS AVERAGE WORK WEEK
HOURS TO RECEIVE THE CHILD CARE COPAYMENT DEDUCTION. THE
DEPARTMENT SHALL APPLY THE COPAYMENT DEDUCTION AFTER RECEIVING
THE REQUIRED DOCUMENTATION.
(8) A FAMILY THAT HAS PREVIOUSLY QUALIFIED FOR A DEDUCTION
IN THE CHILD CARE COPAYMENT SHALL CONTINUE TO REMAIN ELIGIBLE
FOR THE COPAYMENT DEDUCTION IF:
(I) THE FAMILY'S ANNUAL INCOME DOES NOT EXCEED THREE HUNDRED
PERCENT OF THE FEDERAL POVERTY INCOME GUIDELINE OR EIGHTY-FIVE
PERCENT OF THE STATE MEDIAN INCOME, WHICHEVER IS LOWER;
(II) THE PARENT OR CARETAKER HAS BEEN IN COMPLIANCE WITH THE
REQUIREMENTS UNDER PARAGRAPH (7);
(III) THE PARENT OR CARETAKER CONTINUES TO EXCEED THE
MINIMUM WORK REQUIREMENTS BY PERFORMING ADDITIONAL WAGE-EARNING
HOURS;
(IV) THE FAMILY'S ANNUAL INCOME HAS INCREASED AS A RESULT OF
PERFORMING ADDITIONAL WAGE-EARNING HOURS; AND
(V) THE PARENT OR CARETAKER IS CURRENT AND REMAINS CURRENT
WITH MAKING ITS COPAYMENT TO THE CHILD CARE PROVIDER.
(9) THE AVERAGE WORK WEEK OF A FAMILY SHALL BE CALCULATED BY
REVIEWING THE FAMILY'S INCOME STATEMENTS AND TAKING THE NUMBER
OF HOURS WORKED PER PARENT OVER A TWELVE-MONTH PERIOD AND
DIVIDING BY FIFTY-TWO.
(D) NOTWITHSTANDING SUBSECTION (A) OR (C), A PARENT OR
CARETAKER COPAYMENT MAY BE [WAIVED] ADJUSTED IN ACCORDANCE WITH
DEPARTMENT REGULATIONS.
(E) AS USED IN THIS SECTION, "WAGE-EARNING HOURS" MEANS
HOURS FOR WHICH AN INDIVIDUAL IS FINANCIALLY COMPENSATED BY AN
EMPLOYER. THE TERM DOES NOT INCLUDE HOURS SPENT VOLUNTEERING, IN
EDUCATION OR IN JOB TRAINING, UNLESS THOSE HOURS ARE COMPENSATED
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AS A CONDITION OF EMPLOYMENT.
SECTION 3. SECTION 443.1(1.1), (1.4) AND (6) OF THE ACT,
AMENDED JUNE 30, 2007 (P.L.49, NO.16), JUNE 30, 2011 (P.L.89,
NO.22) AND JULY 9, 2013 (P.L.369, NO.55), ARE AMENDED AND CLAUSE
(7) IS AMENDED BY ADDING A SUBCLAUSE TO READ:
SECTION 443.1. MEDICAL ASSISTANCE PAYMENTS FOR INSTITUTIONAL
CARE.--THE FOLLOWING MEDICAL ASSISTANCE PAYMENTS SHALL BE MADE
ON BEHALF OF ELIGIBLE PERSONS WHOSE INSTITUTIONAL CARE IS
PRESCRIBED BY PHYSICIANS:
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(1.1) SUBJECT TO SECTION 813-G, FOR INPATIENT [ACUTE CARE]
HOSPITAL SERVICES PROVIDED DURING A FISCAL YEAR IN WHICH AN
ASSESSMENT IS IMPOSED UNDER ARTICLE VIII-G, PAYMENTS UNDER THE
MEDICAL ASSISTANCE FEE-FOR-SERVICE PROGRAM SHALL BE DETERMINED
IN ACCORDANCE WITH THE DEPARTMENT'S REGULATIONS, EXCEPT AS
FOLLOWS:
(I) IF THE COMMONWEALTH'S APPROVED TITLE XIX STATE PLAN FOR
INPATIENT HOSPITAL SERVICES IN EFFECT FOR THE PERIOD OF JULY 1,
2010, THROUGH JUNE 30, [2016] 2018, SPECIFIES A METHODOLOGY FOR
CALCULATING PAYMENTS THAT IS DIFFERENT FROM THE DEPARTMENT'S
REGULATIONS OR AUTHORIZES ADDITIONAL PAYMENTS NOT SPECIFIED IN
THE DEPARTMENT'S REGULATIONS, SUCH AS INPATIENT DISPROPORTIONATE
SHARE PAYMENTS AND DIRECT MEDICAL EDUCATION PAYMENTS, THE
DEPARTMENT SHALL FOLLOW THE METHODOLOGY OR MAKE THE ADDITIONAL
PAYMENTS AS SPECIFIED IN THE APPROVED TITLE XIX STATE PLAN.
(II) SUBJECT TO FEDERAL APPROVAL OF AN AMENDMENT TO THE
COMMONWEALTH'S APPROVED TITLE XIX STATE PLAN, IN MAKING MEDICAL
ASSISTANCE FEE-FOR-SERVICE PAYMENTS TO ACUTE CARE HOSPITALS FOR
INPATIENT SERVICES PROVIDED ON OR AFTER JULY 1, 2010, THE
DEPARTMENT SHALL USE PAYMENT METHODS AND STANDARDS THAT PROVIDE
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FOR ALL OF THE FOLLOWING:
(A) USE OF THE ALL PATIENT REFINED-DIAGNOSIS RELATED GROUP
(APR/DRG) SYSTEM FOR THE CLASSIFICATION OF INPATIENT STAYS INTO
DRGS.
(B) CALCULATION OF BASE DRG RATES, BASED UPON A STATEWIDE
AVERAGE COST, WHICH ARE ADJUSTED TO ACCOUNT FOR A HOSPITAL'S
REGIONAL LABOR COSTS, TEACHING STATUS, CAPITAL AND MEDICAL
ASSISTANCE PATIENT LEVELS AND SUCH OTHER FACTORS AS THE
DEPARTMENT DETERMINES MAY SIGNIFICANTLY IMPACT THE COSTS THAT A
HOSPITAL INCURS IN DELIVERING INPATIENT SERVICES AND WHICH MAY
BE ADJUSTED BASED ON THE ASSESSMENT REVENUE COLLECTED UNDER
ARTICLE VIII-G.
(C) ADJUSTMENTS TO PAYMENTS FOR OUTLIER CASES WHERE THE
COSTS OF THE INPATIENT STAYS EITHER EXCEED OR ARE BELOW COST
THRESHOLDS ESTABLISHED BY THE DEPARTMENT.
(III) NOTWITHSTANDING SUBPARAGRAPH (I), THE DEPARTMENT MAY
MAKE ADDITIONAL CHANGES TO ITS PAYMENT METHODS AND STANDARDS FOR
INPATIENT HOSPITAL SERVICES CONSISTENT WITH TITLE XIX OF THE
SOCIAL SECURITY ACT, INCLUDING CHANGES TO SUPPLEMENTAL PAYMENTS
CURRENTLY AUTHORIZED IN THE STATE PLAN BASED ON THE AVAILABILITY
OF FEDERAL AND STATE FUNDS.
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(1.4) SUBJECT TO SECTION 813-G, FOR INPATIENT HOSPITAL
SERVICES PROVIDED UNDER THE PHYSICAL HEALTH MEDICAL ASSISTANCE
MANAGED CARE PROGRAM DURING STATE FISCAL YEARS 2012-2013, 2013-
2014, 2014-2015 [AND], 2015-2016, 2016-2017 AND 2017-2018, THE
FOLLOWING SHALL APPLY:
(A) THE DEPARTMENT MAY ADJUST ITS CAPITATION PAYMENTS TO
MEDICAL ASSISTANCE MANAGED CARE ORGANIZATIONS TO PROVIDE
ADDITIONAL FUNDS FOR INPATIENT AND OUTPATIENT HOSPITAL SERVICES.
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(B) FOR AN OUT-OF-NETWORK INPATIENT DISCHARGE OF A RECIPIENT
ENROLLED IN A MEDICAL ASSISTANCE MANAGED CARE ORGANIZATION THAT
OCCURS IN STATE FISCAL YEAR 2012-2013, 2013-2014, 2014-2015
[OR], 2015-2016, 2016-2017 AND 2017-2018, THE MEDICAL ASSISTANCE
MANAGED CARE ORGANIZATION SHALL PAY, AND THE HOSPITAL SHALL
ACCEPT AS PAYMENT IN FULL, THE AMOUNT THAT THE DEPARTMENT'S FEE-
FOR-SERVICE PROGRAM WOULD HAVE PAID FOR THE DISCHARGE IF THE
RECIPIENT WAS ENROLLED IN THE DEPARTMENT'S FEE-FOR-SERVICE
PROGRAM.
(C) NOTHING IN THIS PARAGRAPH SHALL PROHIBIT AN INPATIENT
ACUTE CARE HOSPITAL AND A MEDICAL ASSISTANCE MANAGED CARE
ORGANIZATION FROM EXECUTING A NEW PARTICIPATION AGREEMENT OR
AMENDING AN EXISTING PARTICIPATION AGREEMENT ON OR AFTER JULY 1,
2013.
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(6) FOR PUBLIC NURSING HOME CARE PROVIDED ON OR AFTER JULY
1, 2005, THE DEPARTMENT [SHALL] MAY RECOGNIZE THE COSTS INCURRED
BY COUNTY NURSING FACILITIES TO PROVIDE SERVICES TO ELIGIBLE
PERSONS AS MEDICAL ASSISTANCE PROGRAM EXPENDITURES TO THE EXTENT
THE COSTS QUALIFY FOR FEDERAL MATCHING FUNDS AND SO LONG AS THE
COSTS ARE ALLOWABLE AS DETERMINED BY THE DEPARTMENT AND REPORTED
AND CERTIFIED BY THE COUNTY NURSING FACILITIES IN A FORM AND
MANNER SPECIFIED BY THE DEPARTMENT. EXPENDITURES REPORTED AND
CERTIFIED BY COUNTY NURSING FACILITIES SHALL BE SUBJECT TO
PERIODIC REVIEW AND VERIFICATION BY THE DEPARTMENT OR THE
AUDITOR GENERAL. NOTWITHSTANDING THIS PARAGRAPH, COUNTY NURSING
FACILITIES SHALL BE PAID BASED UPON RATES DETERMINED IN
ACCORDANCE WITH PARAGRAPHS (5) AND (7).
(7) AFTER JUNE 30, 2007, PAYMENTS TO COUNTY AND NONPUBLIC
NURSING FACILITIES ENROLLED IN THE MEDICAL ASSISTANCE PROGRAM AS
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PROVIDERS OF NURSING FACILITY SERVICES SHALL BE DETERMINED IN
ACCORDANCE WITH THE METHODOLOGIES FOR ESTABLISHING PAYMENT RATES
FOR COUNTY AND NONPUBLIC NURSING FACILITIES SPECIFIED IN THE
DEPARTMENT'S REGULATIONS AND THE COMMONWEALTH'S APPROVED TITLE
XIX STATE PLAN FOR NURSING FACILITY SERVICES IN EFFECT AFTER
JUNE 30, 2007. THE FOLLOWING SHALL APPLY:
* * *
(VI) SUBJECT TO FEDERAL APPROVAL OF SUCH AMENDMENTS AS MAY
BE NECESSARY TO THE COMMONWEALTH'S APPROVED TITLE XIX STATE
PLAN, FOR FISCAL YEAR 2015-2016, THE DEPARTMENT SHALL MAKE UP TO
FOUR MEDICAL ASSISTANCE DAY-ONE INCENTIVE PAYMENTS TO QUALIFIED
NONPUBLIC NURSING FACILITIES. THE DEPARTMENT SHALL DETERMINE THE
NONPUBLIC NURSING FACILITIES THAT QUALIFY FOR THE MEDICAL
ASSISTANCE DAY-ONE INCENTIVE PAYMENTS AND CALCULATE THE PAYMENTS
USING THE TOTAL PENNSYLVANIA MEDICAL ASSISTANCE (PA MA) DAYS AND
TOTAL RESIDENT DAYS AS REPORTED BY NONPUBLIC NURSING FACILITIES
UNDER ARTICLE VIII-A. THE DEPARTMENT'S DETERMINATION AND
CALCULATIONS UNDER THIS SUBPARAGRAPH SHALL BE BASED ON THE
NURSING FACILITY ASSESSMENT QUARTERLY RESIDENT DAY REPORTING
FORMS, AS DETERMINED BY THE DEPARTMENT. THE DEPARTMENT SHALL NOT
RETROACTIVELY REVISE A MEDICAL ASSISTANCE DAY-ONE INCENTIVE
PAYMENT AMOUNT BASED ON A NURSING FACILITY'S LATE SUBMISSION OR
REVISION OF ITS REPORT AFTER THE DATES DESIGNATED BY THE
DEPARTMENT. THE DEPARTMENT, HOWEVER, MAY RECOUP PAYMENTS BASED
ON AN AUDIT OF A NURSING FACILITY'S REPORT. THE FOLLOWING SHALL
APPLY:
(A) A NONPUBLIC NURSING FACILITY SHALL MEET ALL OF THE
FOLLOWING CRITERIA TO QUALIFY FOR A MEDICAL ASSISTANCE DAY-ONE
INCENTIVE PAYMENT:
(I) THE NURSING FACILITY SHALL HAVE AN OVERALL OCCUPANCY
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RATE OF AT LEAST EIGHTY-FIVE PERCENT DURING THE RESIDENT DAY
QUARTER. FOR PURPOSES OF DETERMINING A NURSING FACILITY'S
OVERALL OCCUPANCY RATE, A NURSING FACILITY'S TOTAL RESIDENT
DAYS, AS REPORTED BY THE FACILITY UNDER ARTICLE VIII-A, SHALL BE
DIVIDED BY THE PRODUCT OF THE FACILITY'S LICENSED BED CAPACITY,
AT THE END OF THE QUARTER, MULTIPLIED BY THE NUMBER OF CALENDAR
DAYS IN THE QUARTER.
(II) THE NURSING FACILITY SHALL HAVE A MEDICAL ASSISTANCE
OCCUPANCY RATE OF AT LEAST SIXTY-FIVE PERCENT DURING THE
RESIDENT DAY QUARTER. FOR PURPOSES OF DETERMINING A NURSING
FACILITY'S MEDICAL ASSISTANCE OCCUPANCY RATE, THE NURSING
FACILITY'S TOTAL PA MA DAYS SHALL BE DIVIDED BY THE NURSING
FACILITY'S TOTAL RESIDENT DAYS, AS REPORTED BY THE FACILITY
UNDER ARTICLE VIII-A.
(III) THE NURSING FACILITY SHALL BE A NONPUBLIC NURSING
FACILITY FOR A FULL RESIDENT DAY QUARTER PRIOR TO THE APPLICABLE
QUARTERLY REPORTING DUE DATES, AS DETERMINED BY THE DEPARTMENT.
(B) THE DEPARTMENT SHALL CALCULATE A QUALIFIED NONPUBLIC
NURSING FACILITY'S MEDICAL ASSISTANCE DAY-ONE INCENTIVE PAYMENT
AS FOLLOWS:
(I) THE TOTAL FUNDS APPROPRIATED FOR PAYMENTS UNDER THIS
SUBPARAGRAPH SHALL BE DIVIDED BY THE NUMBER OF PAYMENTS, AS
DETERMINED BY THE DEPARTMENT.
(II) TO ESTABLISH THE PER DIEM RATE FOR A PAYMENT, THE
AMOUNT UNDER SUBCLAUSE (I) SHALL BE DIVIDED BY THE TOTAL PA MA
DAYS, AS REPORTED BY ALL QUALIFYING NONPUBLIC NURSING FACILITIES
UNDER ARTICLE VIII-A FOR THAT PAYMENT.
(III) TO DETERMINE A QUALIFYING NONPUBLIC NURSING FACILITY'S
MEDICAL ASSISTANCE DAY-ONE INCENTIVE PAYMENT, THE PER DIEM RATE
CALCULATED FOR THE PAYMENT SHALL BE MULTIPLIED BY A NONPUBLIC
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NURSING FACILITY'S TOTAL PA MA DAYS, AS REPORTED BY THE FACILITY
UNDER ARTICLE VIII-A FOR THE PAYMENT.
(C) FOR FISCAL YEAR 2015-2016, THE STATE FUNDS AVAILABLE FOR
THE NONPUBLIC NURSING FACILITY MEDICAL ASSISTANCE DAY-ONE
INCENTIVE PAYMENTS SHALL EQUAL EIGHT MILLION DOLLARS
($8,000,000).
* * *
SECTION 4. SECTION 443.3(A) OF THE ACT IS AMENDED BY ADDING
A CLAUSE TO READ:
SECTION 443.3. OTHER MEDICAL ASSISTANCE PAYMENTS.--(A)
PAYMENTS ON BEHALF OF ELIGIBLE PERSONS SHALL BE MADE FOR OTHER
SERVICES, AS FOLLOWS:
* * *
(1.1) RATES ESTABLISHED BY THE DEPARTMENT FOR OBSERVATION
SERVICES PROVIDED BY OR FURNISHED UNDER THE DIRECTION OF A
PHYSICIAN AND FURNISHED BY A HOSPITAL. PAYMENT FOR OBSERVATION
SERVICES SHALL BE MADE IN AN AMOUNT SPECIFIED BY THE DEPARTMENT
BY NOTICE IN THE PENNSYLVANIA BULLETIN AND BE EFFECTIVE FOR
DATES OF SERVICE ON OR AFTER JULY 1, 2016. PAYMENT FOR
OBSERVATION SERVICES SHALL BE SUBJECT TO CONDITIONS SPECIFIED IN
THE DEPARTMENT'S REGULATIONS, INCLUDING REGULATIONS ADOPTED BY
THE DEPARTMENT TO IMPLEMENT THIS CLAUSE. PENDING ADOPTION OF
REGULATIONS IMPLEMENTING THIS CLAUSE, THE CONDITIONS FOR PAYMENT
OF OBSERVATION SERVICES SHALL BE SPECIFIED IN A MEDICAL
ASSISTANCE BULLETIN.
* * *
SECTION 5. SECTION 443.11(D) OF THE ACT, ADDED DECEMBER 22,
2011 (P.L.561, NO.121), IS AMENDED TO READ:
SECTION 443.11. MILEAGE REIMBURSEMENT AND PARATRANSIT
SERVICES FOR INDIVIDUALS RECEIVING METHADONE TREATMENT.--* * *
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[(D) THE DEPARTMENT SHALL ISSUE BIENNIAL REPORTS TO THE
GENERAL ASSEMBLY AND THE GOVERNOR DETAILING COSTS AND COST
SAVINGS RELATED TO IMPLEMENTING THE PROVISIONS OF THIS SECTION.
THE FIRST BIENNIAL REPORT SHALL BE ISSUED NOT LATER THAN ONE
YEAR FROM THE EFFECTIVE DATE OF THIS SECTION.]
SECTION 6. SECTION 472 OF THE ACT, AMENDED JULY 7, 2005
(P.L.177, NO.42), IS AMENDED TO READ:
SECTION 472. OTHER COMPUTATIONS AFFECTING COUNTIES.--TO
COMPUTE FOR EACH MONTH THE AMOUNT EXPENDED AS MEDICAL ASSISTANCE
FOR PUBLIC NURSING HOME CARE ON BEHALF OF PERSONS AT EACH PUBLIC
MEDICAL INSTITUTION OPERATED BY A COUNTY, COUNTY INSTITUTION
DISTRICT OR MUNICIPALITY AND THE AMOUNT EXPENDED IN EACH COUNTY
FOR AID TO FAMILIES WITH DEPENDENT CHILDREN ON BEHALF OF
CHILDREN IN FOSTER FAMILY HOMES OR CHILD-CARING INSTITUTIONS,
PLUS THE COST OF ADMINISTERING SUCH ASSISTANCE. FROM SUCH TOTAL
AMOUNT THE DEPARTMENT SHALL DEDUCT THE AMOUNT OF FEDERAL FUNDS
PROPERLY RECEIVED OR TO BE RECEIVED BY THE DEPARTMENT ON ACCOUNT
OF SUCH EXPENDITURES, AND SHALL CERTIFY THE REMAINDER INCREASED
OR DECREASED, AS THE CASE MAY BE, BY ANY AMOUNT BY WHICH THE SUM
CERTIFIED FOR ANY PREVIOUS MONTH DIFFERED FROM THE AMOUNT WHICH
SHOULD HAVE BEEN CERTIFIED FOR SUCH PREVIOUS MONTH, AND BY THE
PROPORTIONATE SHARE OF ANY REFUNDS OF SUCH ASSISTANCE, TO EACH
APPROPRIATE COUNTY, COUNTY INSTITUTION DISTRICT OR MUNICIPALITY.
THE AMOUNTS SO CERTIFIED SHALL BECOME OBLIGATIONS OF SUCH
COUNTIES, COUNTY INSTITUTION DISTRICTS OR MUNICIPALITIES TO BE
PAID TO THE DEPARTMENT FOR ASSISTANCE: PROVIDED, HOWEVER, THAT
FOR FISCAL YEAR 1979-80 AND THEREAFTER, THE OBLIGATIONS OF THE
COUNTIES SHALL BE THE AMOUNTS SO CERTIFIED REPRESENTING AID TO
DEPENDENT CHILDREN FOSTER CARE AS COMPUTED ABOVE PLUS ONE-TENTH
OF THE AMOUNT SO CERTIFIED ABOVE FOR PUBLIC NURSING HOME CARE:
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AND PROVIDED FURTHER, THAT AS TO PUBLIC NURSING HOME CARE, FOR
FISCAL YEAR 2005-2006 AND THEREAFTER, THE OBLIGATIONS OF THE
COUNTIES SHALL BE THE AMOUNT SO CERTIFIED ABOVE, LESS NINE-
TENTHS OF THE NON-FEDERAL SHARE OF PAYMENTS MADE BY THE
DEPARTMENT DURING THE FISCAL YEAR TO COUNTY HOMES FOR PUBLIC
NURSING CARE AT RATES ESTABLISHED IN ACCORDANCE WITH SECTION
443.1(5) AND (7).
SECTION 7. THE ACT IS AMENDED BY ADDING ARTICLES TO READ:
ARTICLE IV-A
(RESERVED)
ARTICLE IV-B
CHILDREN'S HEALTH CARE
SECTION 401-B. DEFINITIONS.
THE FOLLOWING WORDS AND PHRASES WHEN USED IN THIS ARTICLE
SHALL HAVE THE MEANINGS GIVEN TO THEM IN THIS SECTION UNLESS THE
CONTEXT CLEARLY INDICATES OTHERWISE:
"CHILD." AN INDIVIDUAL UNDER 19 YEARS OF AGE.
"CONTRACTOR." AN INSURER AWARDED A CONTRACT UNDER SECTION
404-B TO PROVIDE HEALTH CARE SERVICES UNDER THIS ARTICLE. THE
TERM INCLUDES AN ENTITY AND AN ENTITY'S SUBSIDIARY WHICH IS
ESTABLISHED UNDER:
(1) 40 PA.C.S. CH. 61 (RELATING TO HOSPITAL PLAN
CORPORATIONS) OR 63 (RELATING TO PROFESSIONAL HEALTH SERVICES
PLAN CORPORATIONS);
(2) THE ACT OF MAY 17, 1921 (P.L.682, NO.284), KNOWN AS
THE INSURANCE COMPANY LAW OF 1921; OR
(3) THE ACT OF DECEMBER 29, 1972 (P.L.1701, NO.364),
KNOWN AS THE HEALTH MAINTENANCE ORGANIZATION ACT.
"COUNCIL." THE CHILDREN'S HEALTH ADVISORY COUNCIL ESTABLISHED
IN SECTION 403-B.
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"EPSDT." EARLY AND PERIODIC SCREENING, DIAGNOSIS AND
TREATMENT.
"EXPRESS LANE ELIGIBILITY." A PROCESS WHICH PERMITS THE USE
OF FINDINGS FOR ELIGIBILITY FACTORS, INCLUDING INCOME AND
HOUSEHOLD SIZE, FROM AN EXPRESS LANE PARTNER ADMINISTERING A
GOVERNMENT PROGRAM.
"EXPRESS LANE PARTNER." AN AGENCY DETERMINING ELIGIBILITY FOR
ASSISTANCE FOR ANY OF THE FOLLOWING PROGRAMS:
(1) SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM (SNAP).
(2) CHILD CARE PROVIDED UNDER THE CHILD CARE AND
DEVELOPMENT BLOCK GRANT ACT OF 1990 (PUBLIC LAW 101-508, 42
U.S.C. § 9858 ET SEQ.).
"FUND." THE CHILDREN'S HEALTH FUND.
"GROUP." A GROUP FOR WHICH A HEALTH INSURANCE POLICY IS
WRITTEN IN THIS COMMONWEALTH.
"HEALTH SERVICE CORPORATION." A PROFESSIONAL HEALTH SERVICE
CORPORATION AS DEFINED IN 40 PA.C.S. § 6302 (RELATING TO
DEFINITIONS).
"HEALTHY BEGINNINGS PROGRAM." MEDICAL ASSISTANCE COVERAGE
FOR SERVICES TO CHILDREN AS REQUIRED UNDER TITLE XIX FOR THE
FOLLOWING:
(1) CHILDREN FROM BIRTH TO ONE YEAR OF AGE WHOSE FAMILY
INCOME IS NOT GREATER THAN 185% OF THE FEDERAL POVERTY LEVEL.
(2) CHILDREN ONE THROUGH FIVE YEARS OF AGE WHOSE FAMILY
INCOME IS NOT GREATER THAN 133% OF THE FEDERAL POVERTY LEVEL.
(3) CHILDREN 6 THROUGH 18 YEARS OF AGE WHOSE FAMILY
INCOME IS NOT GREATER THAN 133% OF THE FEDERAL POVERTY LEVEL.
"HMO." AN ENTITY ORGANIZED AND REGULATED UNDER THE HEALTH
MAINTENANCE ORGANIZATION ACT.
"HOSPITAL." AN INSTITUTION HAVING AN ORGANIZED MEDICAL STAFF
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WHICH IS ENGAGED PRIMARILY IN PROVIDING TO INPATIENTS, BY OR
UNDER THE SUPERVISION OF PHYSICIANS, DIAGNOSTIC AND THERAPEUTIC
SERVICES FOR THE CARE OF INJURED, DISABLED, PREGNANT, DISEASED
OR SICK OR MENTALLY ILL INDIVIDUALS. THE TERM INCLUDES
FACILITIES FOR THE DIAGNOSIS AND TREATMENT OF DISORDERS WITHIN
THE SCOPE OF SPECIFIC MEDICAL SPECIALTIES. THE TERM DOES NOT
INCLUDE FACILITIES CARING EXCLUSIVELY FOR THE MENTALLY ILL.
"HOSPITAL PLAN CORPORATION." A HOSPITAL PLAN CORPORATION AS
DEFINED IN 40 PA.C.S. § 6101 (RELATING TO DEFINITIONS).
"INSURER." A HEALTH INSURANCE ENTITY LICENSED IN THIS
COMMONWEALTH TO ISSUE ANY INDIVIDUAL OR GROUP HEALTH, SICKNESS
OR ACCIDENT POLICY OR SUBSCRIBER CONTRACT OR CERTIFICATE THAT
PROVIDES MEDICAL OR HEALTH CARE COVERAGE BY A HEALTH CARE
FACILITY OR LICENSED HEALTH CARE PROVIDER THAT IS OFFERED OR
GOVERNED UNDER ANY OF THE FOLLOWING:
(1) THE INSURANCE COMPANY LAW OF 1921.
(2) THE HEALTH MAINTENANCE ORGANIZATION ACT.
(3) THE ACT OF MAY 18, 1976 (P.L.123, NO.54), KNOWN AS
THE INDIVIDUAL ACCIDENT AND SICKNESS INSURANCE MINIMUM
STANDARDS ACT.
(4) 40 PA.C.S. CH. 61 OR 63.
"MEDICAID." THE FEDERAL MEDICAL ASSISTANCE PROGRAM
ESTABLISHED UNDER TITLE XIX.
"MEDICAL ASSISTANCE." THE STATE PROGRAM OF MEDICAL
ASSISTANCE ESTABLISHED UNDER THIS ACT.
"MID-LEVEL HEALTH PROFESSIONAL." A PHYSICIAN ASSISTANT,
CERTIFIED REGISTERED NURSE PRACTITIONER, NURSE PRACTITIONER OR A
CERTIFIED NURSE MIDWIFE.
"PARENT." A NATURAL PARENT, STEPPARENT, ADOPTIVE PARENT,
GUARDIAN OR CUSTODIAN OF A CHILD.
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"PREMIUM ASSISTANCE PROGRAM." A COMPONENT OF A SEPARATE
CHILD HEALTH PROGRAM, APPROVED UNDER THE STATE PLAN, UNDER WHICH
THE COMMONWEALTH PAYS PART OR ALL OF THE PREMIUM FOR AN ENROLLEE
OR ENROLLEE'S GROUP HEALTH INSURANCE COVERAGE OR COVERAGE UNDER
A GROUP HEALTH PLAN.
"PRESCRIPTION DRUG." A CONTROLLED SUBSTANCE, DRUG OTHER THAN
A CONTROLLED SUBSTANCE OR DEVICE FOR MEDICATION DISPENSED BY
ORDER OF AN APPROPRIATELY LICENSED MEDICAL PROFESSIONAL.
"TERMINATE." THE TERM INCLUDES CANCELLATION, NONRENEWAL AND
RESCISSION.
"TITLE XIX." TITLE XIX OF THE SOCIAL SECURITY ACT (49 STAT.
620, 42 U.S.C. § 301 ET SEQ.)
"TITLE XXI." TITLE XXI OF THE SOCIAL SECURITY ACT (49 STAT.
620, 42 U.S.C. § 1397AA ET SEQ.)
SECTION 402-B. CHILDREN'S HEALTH CARE.
(A) FEDERAL FUNDS.--NOTWITHSTANDING ANY OTHER PROVISION OF
LAW, THE DEPARTMENT SHALL ENSURE THE RECEIPT OF FEDERAL
FINANCIAL PARTICIPATION UNDER TITLE XXI FOR SERVICES PROVIDED
UNDER THIS ARTICLE.
(B) GENERAL CARE.--TO ENSURE THAT INPATIENT HOSPITAL CARE IS
PROVIDED TO ELIGIBLE CHILDREN, EACH PRIMARY CARE PROVIDER
FURNISHING PRIMARY CARE SERVICES SHALL MAKE NECESSARY
ARRANGEMENTS FOR ADMISSION TO THE HOSPITAL AND FOR NECESSARY
SPECIALTY CARE.
(C) ENROLLMENT.--SUBJECT TO THE PROVISIONS OF SECTION 404-B,
AN INSURER RECEIVING FUNDS FROM THE DEPARTMENT TO PROVIDE
COVERAGE OF HEALTH CARE SERVICES UNDER THIS SECTION SHALL
ENROLL, TO THE EXTENT THAT FUNDS ARE AVAILABLE, ANY CHILD WHO
MEETS ALL OF THE FOLLOWING:
(1) IS A RESIDENT OF THIS COMMONWEALTH.
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(2) IS NOT:
(I) COVERED BY A HEALTH INSURANCE PLAN.
(II) COVERED BY A SELF-INSURANCE PLAN.
(III) COVERED BY A SELF-FUNDED PLAN.
(IV) PROVIDED ACCESS TO HEALTH CARE COVERAGE BY
COURT ORDER.
(V) ELIGIBLE FOR OR COVERED BY A MEDICAL ASSISTANCE
PROGRAM ADMINISTERED BY THE DEPARTMENT, INCLUDING THE
HEALTHY BEGINNINGS PROGRAM.
(3) IS QUALIFIED BASED ON INCOME UNDER SUBSECTIONS (D)
AND (E).
(4) MEETS THE CITIZENSHIP REQUIREMENTS OF TITLE XXI.
(D) INCOME LEVELS.--THE PROVISION OF HEALTH CARE COVERAGE
FOR ELIGIBLE CHILDREN SHALL BE IN ACCORDANCE WITH THE FOLLOWING:
(1) FREE TO A CHILD WHOSE FAMILY INCOME IS NO GREATER
THAN 200% OF THE FEDERAL POVERTY LEVEL.
(2) MAY BE SUBSIDIZED BY THE FUND AT A RATE NOT TO
EXCEED 75% OF THE PER-MEMBER PER-MONTH PREMIUM COST FOR A
CHILD WHOSE FAMILY INCOME IS GREATER THAN 200% OF THE FEDERAL
POVERTY LEVEL, BUT NOT GREATER THAN 250% OF THE FEDERAL
POVERTY LEVEL.
(3) MAY BE SUBSIDIZED BY THE FUND AT A RATE NOT TO
EXCEED 65% OF THE PER-MEMBER PER-MONTH PREMIUM COST FOR A
CHILD WHOSE FAMILY INCOME IS GREATER THAN 250% OF THE FEDERAL
POVERTY LEVEL, BUT NOT GREATER THAN 275% OF THE FEDERAL
POVERTY LEVEL.
(4) MAY BE SUBSIDIZED BY THE FUND AT A RATE NOT TO
EXCEED 60% OF THE PER-MEMBER PER-MONTH PREMIUM FOR A CHILD
WHOSE FAMILY INCOME IS GREATER THAN 275% OF THE FEDERAL
POVERTY LEVEL, BUT NOT GREATER THAN 300% OF THE FEDERAL
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POVERTY LEVEL.
(5) NOTWITHSTANDING ANY OTHER PROVISION OF THIS
SUBSECTION, FOR PURPOSES OF DETERMINING THE COST SHARING
OBLIGATIONS OF A FAMILY WITH INCOME LEVELS SPECIFIED UNDER
PARAGRAPHS (2), (3) AND (4), THE PER-MEMBER PER-MONTH PREMIUM
COST SHALL EXCLUDE THE COST RELATED TO AN ASSESSMENT IMPOSED
ON A CONTRACTOR UNDER ARTICLE VIII-I.
(E) INCOME EXCEEDING LIMITS.--THE FOLLOWING APPLY:
(1) FOR AN ELIGIBLE CHILD WHOSE FAMILY INCOME IS GREATER
THAN THE MAXIMUM LEVEL ESTABLISHED UNDER SECTION 404-B(H),
THE FAMILY MAY PURCHASE THE MINIMUM COVERAGE PACKAGE UNDER
SECTION 404-B(E)(9) FOR THAT CHILD AT THE PER-MEMBER PER-
MONTH PREMIUM COST. THE COST SHALL BE DERIVED SEPARATELY FROM
THE OTHER ELIGIBILITY CATEGORIES IN THE PROGRAM. THE FAMILY
MAY PURCHASE THE MINIMUM COVERAGE PACKAGE IF THE FAMILY
DEMONSTRATES ON AN ANNUAL BASIS AND IN A MANNER DETERMINED BY
THE DEPARTMENT THAT THE FAMILY IS UNABLE TO AFFORD INDIVIDUAL
OR GROUP COVERAGE BECAUSE OF ONE OF THE FOLLOWING REASONS:
(I) THE COVERAGE WOULD EXCEED 10% OF THE FAMILY
INCOME.
(II) THE TOTAL COST OF COVERAGE FOR THE CHILD IS
150% OF THE GREATER OF:
(A) THE PREMIUM COST ESTABLISHED UNDER THIS
SUBSECTION FOR THAT SERVICE AREA; OR
(B) THE PREMIUM COST ESTABLISHED UNDER THE
PROGRAM FOR THAT SERVICE AREA.
(2) FOR PURPOSES OF THIS SUBSECTION, THE TERM "COVERAGE"
MAY NOT INCLUDE COVERAGE OFFERED THROUGH ACCIDENT ONLY, FIXED
INDEMNITY, LIMITED BENEFIT, CREDIT, DENTAL, VISION, SPECIFIED
DISEASE, MEDICARE SUPPLEMENT, CIVILIAN HEALTH AND MEDICAL
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PROGRAM OF THE UNIFORMED SERVICES (CHAMPUS) SUPPLEMENT, LONG-
TERM CARE OR DISABILITY INCOME, WORKERS' COMPENSATION OR
AUTOMOBILE MEDICAL PAYMENT INSURANCE.
(3) FOR PURPOSES OF THIS SUBSECTION, THE PER-MEMBER PER-
MONTH PREMIUM COST SHALL EXCLUDE THE COST RELATED TO THE
ASSESSMENT IMPOSED ON A CONTRACTOR UNDER ARTICLE VIII-I.
(F) POWERS AND DUTIES.--
(1) FOR ENROLLEES UNDER SUBSECTIONS (D)(2), (3) OR (4)
OR (E), THE FOLLOWING APPLY:
(I) THE DEPARTMENT SHALL HAVE THE AUTHORITY TO
IMPOSE COPAYMENTS FOR THE FOLLOWING SERVICES, EXCEPT AS
OTHERWISE PROHIBITED BY LAW:
(A) OUTPATIENT VISITS.
(B) EMERGENCY ROOM VISITS.
(C) PRESCRIPTION MEDICATIONS.
(D) ANY OTHER SERVICE DEFINED BY THE DEPARTMENT.
(II) THE DEPARTMENT SHALL HAVE THE AUTHORITY TO
ESTABLISH AND ADJUST THE LEVELS OF THESE COPAYMENTS IN
ORDER TO IMPOSE REASONABLE COST SHARING AND TO ENCOURAGE
APPROPRIATE UTILIZATION OF THESE SERVICES. THE PREMIUMS
AND COPAYMENTS FOR ENROLLEES UNDER SUBSECTION (D)(2), (3)
OR (4) MAY NOT AMOUNT TO MORE THAN THE PERCENT OF TOTAL
HOUSEHOLD INCOME WHICH IS IN ACCORDANCE WITH THE
REQUIREMENTS OF THE CENTERS FOR MEDICARE AND MEDICAID
SERVICES.
(2) THE DEPARTMENT SHALL:
(I) ADMINISTER THE CHILDREN'S HEALTH CARE PROGRAM IN
ACCORDANCE WITH THIS ARTICLE.
(II) REVIEW ALL BIDS AND APPROVE AND EXECUTE ALL
CONTRACTS FOR THE PURPOSE OF EXPANDING ACCESS TO HEALTH
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CARE SERVICES FOR ELIGIBLE CHILDREN AS PROVIDED FOR IN
THIS ARTICLE.
(III) CONDUCT MONITORING AND OVERSIGHT OF CONTRACTS.
(IV) ISSUE AN ANNUAL REPORT TO THE GOVERNOR, THE
GENERAL ASSEMBLY AND THE PUBLIC FOR EACH CALENDAR YEAR NO
LATER THAN MARCH 1 OF EACH YEAR PROVIDING FOR THE
FOLLOWING:
(A) THE PRIMARY HEALTH SERVICES FUNDED FOR THE
YEAR.
(B) THE OUTREACH AND ENROLLMENT EFFORTS AND THE
NUMBER OF CHILDREN BY COUNTY AND BY PERCENT OF THE
FEDERAL POVERTY LEVEL WHO ARE RECEIVING HEALTH CARE
SERVICES.
(C) THE PROJECTED NUMBER OF ELIGIBLE CHILDREN BY
COUNTY AND BY PERCENT OF THE FEDERAL POVERTY LEVEL.
(D) THE NUMBER OF ELIGIBLE CHILDREN ON WAITING
LISTS FOR ENROLLMENT IN THE CHILDREN'S HEALTH
INSURANCE PROGRAM UNDER THIS ARTICLE BY COUNTY AND BY
PERCENT OF THE FEDERAL POVERTY LEVEL.
(E) THE DETAILS OF THE DEPARTMENT'S EFFORTS ON
THE IMPLEMENTATION OF EXPRESS LANE ELIGIBILITY.
(V) IN CONSULTATION WITH APPROPRIATE COMMONWEALTH
AGENCIES, COORDINATE THE DEVELOPMENT AND SUPERVISION OF
THE OUTREACH PLAN REQUIRED UNDER SECTION 405-B.
(VI) IN CONSULTATION WITH APPROPRIATE COMMONWEALTH
AGENCIES, MONITOR, REVIEW AND EVALUATE THE ADEQUACY,
ACCESSIBILITY AND AVAILABILITY OF SERVICES DELIVERED TO
CHILDREN WHO ARE ENROLLED IN THE CHILDREN'S HEALTH
INSURANCE PROGRAM UNDER THIS ARTICLE.
(VII) ENTER INTO ARRANGEMENTS, INCLUDING MEMORANDA
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OF UNDERSTANDING, WITH THE INSURANCE DEPARTMENT AND OTHER
APPROPRIATE COMMONWEALTH OR FEDERAL AGENCIES, AS MAY BE
NECESSARY TO CARRY OUT THE DEPARTMENT'S DUTIES UNDER
THIS ARTICLE.
(3) THE DEPARTMENT MAY PROMULGATE REGULATIONS NECESSARY
FOR THE IMPLEMENTATION AND ADMINISTRATION OF THIS ARTICLE.
SECTION 403-B. CHILDREN'S HEALTH ADVISORY COUNCIL.
THE CHILDREN'S HEALTH ADVISORY COUNCIL IS ESTABLISHED WITHIN
THE DEPARTMENT AS AN ADVISORY COUNCIL. THE FOLLOWING SHALL
APPLY:
(1) THE COUNCIL SHALL CONSIST OF 16 VOTING MEMBERS.
MEMBERS PROVIDED FOR IN SUBPARAGRAPHS (IV), (V), (VI), (VII),
(VIII), (XIII), (XIV), (XV) AND (XVI) SHALL BE APPOINTED BY
THE SECRETARY. THE COUNCIL SHALL BE GEOGRAPHICALLY BALANCED
ON A STATEWIDE BASIS AND SHALL INCLUDE:
(I) THE SECRETARY OF HEALTH EX OFFICIO OR A
DESIGNEE.
(II) THE INSURANCE COMMISSIONER EX OFFICIO OR A
DESIGNEE.
(III) THE SECRETARY EX OFFICIO OR A DESIGNEE.
(IV) A REPRESENTATIVE WITH EXPERIENCE IN CHILDREN'S
HEALTH FROM A SCHOOL OF PUBLIC HEALTH LOCATED IN THIS
COMMONWEALTH.
(V) A PHYSICIAN WITH EXPERIENCE IN CHILDREN'S HEALTH
APPOINTED FROM A LIST OF THREE QUALIFIED PERSONS
RECOMMENDED BY THE PENNSYLVANIA MEDICAL SOCIETY.
(VI) A REPRESENTATIVE OF A CHILDREN'S HOSPITAL OR A
HOSPITAL WITH A PEDIATRIC OUTPATIENT CLINIC APPOINTED
FROM A LIST OF THREE PERSONS SUBMITTED BY THE HOSPITAL
ASSOCIATION OF PENNSYLVANIA.
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(VII) A PARENT OF A CHILD WHO RECEIVES PRIMARY
HEALTH CARE COVERAGE FROM THE FUND.
(VIII) A MID-LEVEL PROFESSIONAL APPOINTED FROM LISTS
OF NAMES RECOMMENDED BY STATEWIDE ASSOCIATIONS
REPRESENTING MID-LEVEL HEALTH PROFESSIONALS.
(IX) A SENATOR APPOINTED BY THE PRESIDENT PRO
TEMPORE OF THE SENATE.
(X) A SENATOR APPOINTED BY THE MINORITY LEADER OF
THE SENATE.
(XI) A REPRESENTATIVE APPOINTED BY THE SPEAKER OF
THE HOUSE OF REPRESENTATIVES.
(XII) A REPRESENTATIVE APPOINTED BY THE MINORITY
LEADER OF THE HOUSE OF REPRESENTATIVES.
(XIII) A REPRESENTATIVE FROM A PRIVATE NONPROFIT
FOUNDATION.
(XIV) A REPRESENTATIVE OF BUSINESS WHO IS NOT A
CONTRACTOR OR PROVIDER OF PRIMARY HEALTH CARE INSURANCE
UNDER THIS ARTICLE.
(XV) A REPRESENTATIVE OF A NONPROFIT BUSINESS WHO IS
A CONTRACTOR OR PROVIDER OF PRIMARY HEALTH INSURANCE
UNDER THIS ARTICLE.
(XVI) A REPRESENTATIVE OF A FOR PROFIT BUSINESS WHO
IS A CONTRACTOR OR PROVIDER OF PRIMARY HEALTH INSURANCE
UNDER THIS ARTICLE.
(2) IF A SPECIFIED ORGANIZATION CEASES TO EXIST OR FAILS
TO MAKE A RECOMMENDATION WITHIN 90 DAYS OF A REQUEST TO DO
SO, THE COUNCIL SHALL SPECIFY A NEW EQUIVALENT ORGANIZATION
TO FULFILL THE RESPONSIBILITIES OF THIS SECTION.
(3) THE SECRETARY SHALL SERVE AS CHAIRPERSON OF THE
COUNCIL. THE MEMBERS OF THE COUNCIL SHALL ANNUALLY ELECT, BY
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A MAJORITY VOTE OF THE MEMBERS, A VICE CHAIRPERSON FROM AMONG
THE MEMBERS OF THE COUNCIL.
(4) THE PRESENCE OF NINE MEMBERS SHALL CONSTITUTE A
QUORUM FOR THE TRANSACTING OF ANY BUSINESS. AN ACT BY A
MAJORITY OF THE MEMBERS PRESENT AT A MEETING AT WHICH THERE
IS A QUORUM SHALL BE DEEMED TO BE THAT OF THE COUNCIL.
(5) ALL MEETINGS OF THE COUNCIL SHALL BE CONDUCTED IN
ACCORDANCE WITH 65 PA.C.S. CH. 7 (RELATING TO OPEN MEETINGS)
EXCEPT AS PROVIDED IN THIS SECTION. MEETING MUST BE IN
ACCORDANCE WITH THE FOLLOWING:
(I) THE COUNCIL SHALL MEET AT LEAST TWICE PER YEAR
AND MAY PROVIDE FOR SPECIAL MEETINGS AS THE COUNCIL DEEMS
NECESSARY.
(II) MEETING DATES SHALL BE SET BY A MAJORITY VOTE
OF MEMBERS OF THE COUNCIL OR BY CALL OF THE CHAIRPERSON
UPON SEVEN DAYS' NOTICE TO ALL MEMBERS.
(III) THE COUNCIL SHALL PUBLISH NOTICE OF THE
COUNCIL'S MEETINGS IN THE PENNSYLVANIA BULLETIN. THE
NOTICE MUST SPECIFY THE DATE, TIME AND PLACE OF THE
MEETING AND SHALL STATE THAT THE COUNCIL'S MEETINGS ARE
OPEN TO THE GENERAL PUBLIC.
(IV) ALL ACTION TAKEN BY THE COUNCIL SHALL BE TAKEN
IN OPEN PUBLIC SESSION AND MAY NOT BE TAKEN EXCEPT UPON A
MAJORITY VOTE OF THE MEMBERS PRESENT AT A MEETING AT
WHICH A QUORUM IS PRESENT.
(6) THE MEMBERS OF THE COUNCIL SHALL NOT RECEIVE A
SALARY OR PER DIEM ALLOWANCE FOR SERVING AS MEMBERS OF THE
COUNCIL BUT SHALL BE REIMBURSED FOR ACTUAL AND NECESSARY
EXPENSES INCURRED IN THE PERFORMANCE OF THE MEMBER'S DUTIES.
(7) TERMS OF COUNCIL MEMBERS SHALL BE AS FOLLOWS:
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(I) THE APPOINTED MEMBERS SHALL SERVE FOR A TERM OF
THREE YEARS AND SHALL CONTINUE TO SERVE UNTIL A SUCCESSOR
IS APPOINTED.
(II) AN APPOINTED MEMBER SHALL NOT BE ELIGIBLE TO
SERVE MORE THAN TWO FULL CONSECUTIVE TERMS OF THREE
YEARS. VACANCIES SHALL BE FILLED IN THE SAME MANNER AS
THE ORIGINAL APPOINTMENT, WITHIN 60 DAYS OF THE VACANCY.
(III) AN APPOINTED MEMBER MAY BE REMOVED BY THE
APPOINTING AUTHORITY FOR JUST CAUSE AND BY A VOTE OF AT
LEAST SEVEN MEMBERS OF THE COUNCIL.
(8) THE COUNCIL SHALL REVIEW OUTREACH ACTIVITIES AND MAY
MAKE RECOMMENDATIONS TO THE DEPARTMENT.
(9) THE COUNCIL SHALL REVIEW AND EVALUATE THE
ACCESSIBILITY AND AVAILABILITY OF SERVICES DELIVERED TO
CHILDREN ENROLLED IN THE PROGRAM.
SECTION 404-B. CONTRACTS AND COVERAGE PACKAGES.
(A) PAID FROM FUND.--IN ADDITION TO ANY OTHER REQUIREMENTS
PROVIDED BY LAW, THE FUND SHALL BE OPERATED IN ACCORDANCE WITH
THE FOLLOWING:
(1) THE FUND MUST BE DEDICATED EXCLUSIVELY FOR
DISTRIBUTION BY THE DEPARTMENT THROUGH CONTRACTS IN ORDER TO
PROVIDE FREE AND SUBSIDIZED HEALTH CARE SERVICES UNDER THIS
ARTICLE, BASED ON ACTUARIALLY SOUND AND ADEQUATE REVIEW, AND
TO DEVELOP AND IMPLEMENT OUTREACH ACTIVITIES REQUIRED UNDER
SECTION 405-B.
(2) THE FUND, ALONG WITH FEDERAL, STATE AND OTHER FUNDS
AVAILABLE FOR THE PROGRAM, MUST BE USED FOR HEALTH CARE
COVERAGE FOR CHILDREN AS SPECIFIED IN THIS ARTICLE. THE
DEPARTMENT SHALL ENSURE THAT THE PROGRAM IS IMPLEMENTED
STATEWIDE.
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(3) THE DEPARTMENT MUST AWARD CONTRACTS PAID FROM THE
FUND IN ACCORDANCE WITH THE FOLLOWING:
(I) ALL CONTRACTS AWARDED UNDER THIS SUBSECTION MUST
BE AWARDED THROUGH A COMPETITIVE PROCUREMENT PROCESS. THE
DEPARTMENT AND THE INSURANCE DEPARTMENT MUST USE THEIR
BEST EFFORTS TO ENSURE THAT ELIGIBLE CHILDREN ACROSS THIS
COMMONWEALTH HAVE ACCESS TO HEALTH CARE SERVICES TO BE
PROVIDED UNDER THIS ARTICLE.
(II) NO MORE THAN 10% OF THE AMOUNT OF THE CONTRACT
MAY BE USED FOR ADMINISTRATIVE EXPENSES OF THE
CONTRACTOR. IF A CONTRACTOR PRESENTS DOCUMENTED EVIDENCE
THAT ADMINISTRATIVE EXPENSES FOR PURPOSES OF EXPANDED
OUTREACH AND SYSTEMS AND OPERATIONAL CHANGES ARE IN
EXCESS OF 10% OF THE AMOUNT OF THE CONTRACT, THE
DEPARTMENT SHALL MAKE AN ADDITIONAL ALLOTMENT OF FUNDS,
NOT TO EXCEED 2% OF THE CONTRACT, TO THE CONTRACTOR TO
THE EXTENT THAT THE DEPARTMENT FINDS THE EXPENSES
REASONABLE AND NECESSARY.
(III) NO LESS THAN 84% OF THE AMOUNT OF THE CONTRACT
SHALL BE USED TO PROVIDE HEALTH CARE SERVICES FOR
CHILDREN ELIGIBLE FOR CARE UNDER THIS ARTICLE.
(IV) IN DETERMINING THE AMOUNT OF THE CONTRACT WHICH
MAY BE USED FOR THE PURPOSES SPECIFIED IN SUBPARAGRAPHS
(II) AND (III), ANY FEDERAL AND STATE TAXES THAT WOULD BE
DEDUCTED FROM PREMIUM REVENUE IN DETERMINING AN ISSUER'S
MEDICAL LOSS RATIO UNDER 45 CFR 158.221 (RELATING TO
FORMULA FOR CALCULATING AN INSURER'S MEDICAL LOSS RATIO),
INCLUDING AN ASSESSMENT IMPOSED ON A CONTRACTOR UNDER
ARTICLE VIII-I, SHALL BE EXCLUDED.
(B) SOLICITATION OF CONTRACTS.--THE DEPARTMENT MUST SOLICIT
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BIDS AND AWARD CONTRACTS THROUGH A COMPETITIVE PROCUREMENT
PROCESS IN ACCORDANCE WITH THE FOLLOWING:
(1) TO THE FULLEST EXTENT PRACTICABLE, CONTRACTS SHALL
BE AWARDED TO INSURERS THAT CONTRACT WITH PROVIDERS TO
PROVIDE PRIMARY CARE SERVICES FOR ENROLLEES ON A COST-
EFFECTIVE BASIS. THE DEPARTMENT SHALL REQUIRE CONTRACTORS TO
USE APPROPRIATE COST-MANAGEMENT METHODS SO THAT BASIC PRIMARY
COVERAGE SERVICES CAN BE PROVIDED TO THE MAXIMUM NUMBER OF
ELIGIBLE CHILDREN AND, IF POSSIBLE, TO PURSUE AND UTILIZE
AVAILABLE PUBLIC AND PRIVATE FUNDS.
(2) TO THE FULLEST EXTENT PRACTICABLE, THE DEPARTMENT
MUST REQUIRE THAT A CONTRACTOR COMPLY WITH ALL PROCEDURES
RELATING TO COORDINATION OF HEALTH CARE SERVICES AS REQUIRED
BY THE DEPARTMENT OR THE INSURANCE DEPARTMENT.
(3) CONTRACTS MAY BE FOR A TERM OF UP TO THREE YEARS,
WITH THE OPTION TO EXTEND FOR TWO ONE-YEAR PERIODS.
(C) BIDDING.--UPON RECEIPT OF A SOLICITATION FROM THE
DEPARTMENT, EACH HEALTH SERVICE CORPORATION AND HOSPITAL PLAN
CORPORATION OR THEIR ENTITIES DOING BUSINESS IN THIS
COMMONWEALTH SHALL SUBMIT A BID OR PROPOSAL TO THE DEPARTMENT TO
CARRY OUT THE PURPOSES OF THIS ARTICLE IN THE AREA SERVICED BY
THE CORPORATION.
(D) BIDDING BY OTHER INSURERS.--ALL OTHER INSURERS MAY
SUBMIT A BID OR PROPOSAL TO THE DEPARTMENT TO CARRY OUT THE
PURPOSES OF THIS ARTICLE.
(E) DUTIES OF CONTRACTOR.--A CONTRACTOR WITH WHOM THE
DEPARTMENT ENTERS INTO A CONTRACT SHALL DO THE FOLLOWING:
(1) ENSURE TO THE MAXIMUM EXTENT POSSIBLE THAT ELIGIBLE
CHILDREN HAVE ACCESS TO PRIMARY HEALTH CARE PHYSICIANS AND
NURSE PRACTITIONERS WITHIN THE CONTRACTOR'S SERVICE AREA.
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(2) CONTRACT WITH QUALIFIED, COST-EFFECTIVE PROVIDERS,
WHICH MAY INCLUDE PRIMARY HEALTH CARE PHYSICIANS, NURSE
PRACTITIONERS, CLINICS AND HMOS, TO PROVIDE PRIMARY AND
PREVENTIVE HEALTH CARE FOR ENROLLEES ON A BASIS BEST
CALCULATED TO MANAGE THE COSTS OF THE SERVICES, INCLUDING,
BUT NOT LIMITED TO, USING MANAGED HEALTH CARE TECHNIQUES AND
OTHER APPROPRIATE MEDICAL COST-MANAGEMENT METHODS.
(3) ENSURE THAT THE FAMILY OF A CHILD WHO MAY BE
ELIGIBLE FOR MEDICAL ASSISTANCE RECEIVES ASSISTANCE IN
APPLYING FOR MEDICAL ASSISTANCE.
(4) MAINTAIN WAITING LISTS OF CHILDREN FINANCIALLY
ELIGIBLE FOR COVERAGE WHO HAVE APPLIED FOR COVERAGE BUT WHO
WERE NOT ENROLLED DUE TO LACK OF FUNDS.
(5) NOTIFY FAMILIES OF CHILDREN WHO ARE PAYING A PREMIUM
OF ANY CHANGES IN THE PREMIUM OR COPAYMENT REQUIREMENTS.
(6) COLLECT PREMIUMS OR COPAYMENTS FROM THE FAMILY OF A
CHILD RECEIVING COVERAGE AS MAY BE REQUIRED.
(7) CANCEL COVERAGE FOR NONPAYMENT OF PREMIUM, IN
ACCORDANCE WITH ALL APPLICABLE INSURANCE LAWS.
(8) STRONGLY ENCOURAGE ALL PROVIDERS WHO PROVIDE PRIMARY
CARE TO ELIGIBLE CHILDREN TO PARTICIPATE IN MEDICAL
ASSISTANCE AS QUALIFIED EPSDT PROVIDERS AND TO CONTINUE TO
PROVIDE CARE TO CHILDREN WHO BECOME INELIGIBLE FOR COVERAGE
UNDER THE PROVISIONS OF THIS ARTICLE BUT WHO QUALIFY FOR
MEDICAL ASSISTANCE.
(9) SUBJECT TO ANY NECESSARY FEDERAL APPROVAL, PROVIDE
THE FOLLOWING MINIMUM COVERAGE PACKAGE, WHICH MAY NOT
CONFLICT WITH FEDERAL LAW, REGULATION OR OTHER GUIDANCE, FOR
ELIGIBLE CHILDREN:
(I) PREVENTIVE CARE. THIS SUBPARAGRAPH SHALL
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INCLUDE:
(A) WELL-CHILD CARE VISITS IN ACCORDANCE WITH
THE SCHEDULE ESTABLISHED BY THE AMERICAN ACADEMY OF
PEDIATRICS AND THE SERVICES RELATED TO THOSE VISITS,
INCLUDING IMMUNIZATIONS, HEALTH EDUCATION,
TUBERCULOSIS TESTING AND DEVELOPMENTAL SCREENING IN
ACCORDANCE WITH THE ROUTINE SCHEDULE OF WELL-CHILD
CARE VISITS.
(B) A COMPREHENSIVE PHYSICAL EXAMINATION,
INCLUDING X-RAYS IF NECESSARY, FOR ANY CHILD
EXHIBITING SYMPTOMS OF POSSIBLE CHILD ABUSE.
(II) DIAGNOSIS AND TREATMENT OF ILLNESS OR INJURY,
INCLUDING ALL MEDICALLY NECESSARY SERVICES RELATED TO THE
DIAGNOSIS AND TREATMENT OF SICKNESS AND INJURY AND OTHER
CONDITIONS PROVIDED ON AN AMBULATORY BASIS, SUCH AS
LABORATORY TESTS, WOUND DRESSING AND CASTING TO
IMMOBILIZE FRACTURES.
(III) INJECTIONS AND MEDICATIONS PROVIDED AT THE
TIME OF THE OFFICE VISIT OR THERAPY AND OUTPATIENT
SURGERY PERFORMED IN THE OFFICE, A HOSPITAL OR
FREESTANDING AMBULATORY SERVICE CENTER, INCLUDING
ANESTHESIA PROVIDED IN CONJUNCTION WITH SUCH SERVICE OR
DURING EMERGENCY MEDICAL SERVICE.
(IV) EMERGENCY ACCIDENT AND EMERGENCY MEDICAL CARE.
(V) PRESCRIPTION DRUGS.
(VI) EMERGENCY, PREVENTIVE AND ROUTINE DENTAL CARE.
THIS SUBPARAGRAPH DOES NOT INCLUDE ORTHODONTIA OR
COSMETIC SURGERY.
(VII) EMERGENCY, PREVENTIVE AND ROUTINE VISION CARE,
INCLUDING THE COST OF CORRECTIVE LENSES AND FRAMES, NOT
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TO EXCEED TWO PRESCRIPTIONS PER YEAR.
(VIII) EMERGENCY, PREVENTIVE AND ROUTINE HEARING
CARE.
(IX) INPATIENT HOSPITALIZATION.
(10) THE DEPARTMENT MAY IMPLEMENT A PREMIUM ASSISTANCE
PROGRAM PERMITTED UNDER FEDERAL REGULATIONS AND AS PERMITTED
THROUGH FEDERAL WAIVER OR STATE PLAN AMENDMENT MADE PURSUANT
TO THIS ARTICLE. NOTWITHSTANDING ANY OTHER LAW TO THE
CONTRARY, IF IT IS MORE COST EFFECTIVE TO PURCHASE HEALTH
CARE FROM A PARENT'S EMPLOYER-BASED PROGRAM AND THE EMPLOYER-
BASED PROGRAM MEETS THE MINIMUM COVERAGE REQUIREMENTS,
EMPLOYER-BASED COVERAGE MAY BE PURCHASED IN PLACE OF
ENROLLMENT IN THE CHILDREN'S HEALTH INSURANCE PROGRAM UNDER
THIS ARTICLE. AN INSURER SHALL HONOR A REQUEST FOR ENROLLMENT
AND PURCHASE OF EMPLOYEE GROUP HEALTH INSURANCE REQUESTED ON
BEHALF OF AN INDIVIDUAL APPLYING FOR COVERAGE UNDER THIS
ARTICLE IF THE INDIVIDUAL:
(I) IS A RESIDENT OF THIS COMMONWEALTH;
(II) IS QUALIFIED BASED ON INCOME UNDER SECTION 402-
B(D); AND
(III) MEETS THE CITIZENSHIP REQUIREMENTS OF SECTION
402-B(C)(1)(IV).
(11) THE DEPARTMENT SHALL HAVE THE AUTHORITY TO REVIEW,
AUDIT AND APPROVE ANNUAL ADMINISTRATIVE EXPENSES INCURRED BY
CONTRACTORS UNDER THIS SECTION.
(12) EXCEPT FOR CHILDREN COVERED UNDER PARAGRAPH (10),
EACH CONTRACTOR SHALL PROVIDE A COVERAGE IDENTIFICATION CARD
TO EACH ELIGIBLE CHILD COVERED UNDER CONTRACTS EXECUTED UNDER
THIS ARTICLE. THE CARD MUST NOT SPECIFICALLY IDENTIFY THE
HOLDER AS LOW INCOME.
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(F) WAIVER OF MINIMUM.--THE DEPARTMENT MAY GRANT A WAIVER OF
THE MINIMUM COVERAGE PACKAGE OF SUBSECTION (E)(9) UPON
DEMONSTRATION BY THE APPLICANT THAT THE APPLICANT IS PROVIDING
HEALTH CARE SERVICES FOR ELIGIBLE CHILDREN THAT MEET THE
PURPOSES AND INTENT OF THIS ARTICLE.
(G) REVIEW.--THE DEPARTMENT, IN CONSULTATION WITH
APPROPRIATE COMMONWEALTH AGENCIES, MUST REVIEW ENROLLMENT
PATTERNS FOR BOTH THE FREE COVERAGE PROGRAM AND THE SUBSIDIZED
COVERAGE PROGRAM. THE DEPARTMENT SHALL CONSIDER THE
RELATIONSHIP, IF ANY, AMONG ENROLLMENT, ENROLLMENT FEES, INCOME
LEVELS AND FAMILY COMPOSITION. BASED ON THE RESULTS OF THIS
STUDY AND THE AVAILABILITY OF FUNDS, THE DEPARTMENT IS
AUTHORIZED TO ADJUST THE MAXIMUM INCOME CEILING FOR FREE
COVERAGE AND THE MAXIMUM INCOME CEILING FOR SUBSIDIZED COVERAGE
BY REGULATION. THE MAXIMUM INCOME CEILING FOR FREE COVERAGE MAY
NOT BE RAISED ABOVE 200% OF THE FEDERAL POVERTY LEVEL.
(H) LIMIT.--NOTWITHSTANDING SUBSECTION (G), AND SUBJECT TO
THE PROVISIONS OF SECTION 407-B, THE MAXIMUM INCOME CEILING FOR
SUBSIDIZED COVERAGE UNDER SECTION 402-B(D)(2),(3) OR (4) MAY NOT
BE RAISED ABOVE 300% OF THE FEDERAL POVERTY LEVEL.
SECTION 405-B. OUTREACH.
(A) PLAN.--THE DEPARTMENT, IN CONSULTATION WITH APPROPRIATE
COMMONWEALTH AGENCIES, MUST COORDINATE THE DEVELOPMENT OF AN
OUTREACH PLAN TO INFORM POTENTIAL CONTRACTORS, PROVIDERS AND
ENROLLEES REGARDING ELIGIBILITY AND AVAILABLE COVERAGE. THE PLAN
MUST INCLUDE PROVISIONS FOR ALL OF THE FOLLOWING:
(1) REACHING SPECIAL POPULATIONS, INCLUDING NONWHITE AND
NON-ENGLISH-SPEAKING CHILDREN AND CHILDREN WITH DISABILITIES.
(2) REACHING DIFFERENT GEOGRAPHIC AREAS, INCLUDING RURAL
AND INNER-CITY AREAS.
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(3) ENSURING THAT SPECIAL EFFORTS ARE COORDINATED WITHIN
THE OVERALL OUTREACH ACTIVITIES THROUGHOUT THIS COMMONWEALTH.
(4) COMPARING CHILDREN ENROLLED IN CHILD CARE PROVIDED
UNDER THE CHILD CARE AND DEVELOPMENT BLOCK GRANT ACT OF 1990
(PUBLIC LAW 101-508, 42 U.S.C. § 9858 ET SEQ.) OR ENROLLED IN
THE SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM IN THE
DETERMINATION OF A CHILD'S ELIGIBILITY FOR COVERAGE UNDER
THIS ARTICLE AND IMPLEMENT EXPRESS LANE ELIGIBILITY AS
APPROPRIATE. THE DEPARTMENT IS AUTHORIZED TO EXPAND THE
AGENCIES IDENTIFIED AS EXPRESS LANE PARTNERS BY ISSUANCE OF A
STATEMENT OF POLICY.
(5) NOTICE OF THE EXISTENCE OF AND ELIGIBILITY FOR THE
PROGRAM SHALL BE PREPARED BY THE DEPARTMENT AND PROVIDED TO
THE DEPARTMENT OF EDUCATION FOR DISSEMINATION TO NONPUBLIC
AND PUBLIC SCHOOLS ELECTRONICALLY, ON AN ANNUAL BASIS, NOT
LATER THAN AUGUST 15.
(B) REVIEW.--THE COUNCIL SHALL REVIEW THE OUTREACH
ACTIVITIES AND RECOMMEND CHANGES AS THE COUNCIL DEEMS IN THE
BEST INTERESTS OF THE CHILDREN TO BE SERVED.
SECTION 406-B. PAYOR OF LAST RESORT; INSURANCE COVERAGE.
THE CONTRACTOR MAY NOT PAY A CLAIM ON BEHALF OF AN ENROLLED
CHILD UNLESS ALL OTHER FEDERAL, STATE, LOCAL OR PRIVATE
RESOURCES AVAILABLE TO THE CHILD OR THE CHILD'S FAMILY ARE
UTILIZED FIRST. THE DEPARTMENT, IN COOPERATION WITH THE
INSURANCE DEPARTMENT, MUST DETERMINE IF ANY INSURANCE COVERAGE
IS AVAILABLE TO THE CHILD THROUGH A CUSTODIAL OR NONCUSTODIAL
PARENT ON AN EMPLOYMENT-RELATED OR OTHER GROUP BASIS. IF SUCH
INSURANCE COVERAGE IS AVAILABLE, THE CHILD'S ELIGIBILITY UNDER
SECTION 402-B AND THE MOST COST-EFFECTIVE MEANS OF PROVIDING
COVERAGE FOR THAT CHILD MUST BE REEVALUATED.
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SECTION 407-B. STATE PLAN.
THE DEPARTMENT MAY AMEND THE STATE PLAN AS NECESSARY TO CARRY
OUT THE PROVISIONS OF THIS ARTICLE.
SECTION 408-B. LIMITATION ON EXPENDITURE OF FUNDS.
THE TOTAL AMOUNT OF ANNUAL CONTRACT AWARDS AUTHORIZED UNDER
THIS ARTICLE MAY NOT EXCEED THE AMOUNT OF CIGARETTE TAX RECEIPTS
ANNUALLY DEPOSITED INTO THE FUND UNDER SECTION 1296 OF THE ACT
OF MARCH 4, 1971 (P.L.6, NO.2), KNOWN AS THE TAX REFORM CODE OF
1971, AND ANY OTHER FEDERAL OR STATE FUNDS RECEIVED THROUGH THE
FUND. THE PROVISION OF CHILDREN'S HEALTH CARE THROUGH THE FUND
SHALL IN NO WAY CONSTITUTE AN ENTITLEMENT DERIVED FROM THE
COMMONWEALTH OR A CLAIM ON ANY OTHER FUNDS OF THE COMMONWEALTH.
SECTION 409-B. EXPIRATION.
(A) GENERAL RULE.--THIS ARTICLE SHALL EXPIRE ON THE EARLIER
OF:
(1) DECEMBER 31, 2017.
(2) NINETY DAYS AFTER THE DATE ON WHICH FEDERAL FUNDING
FOR THE PROGRAM SHALL CEASE TO BE AVAILABLE.
(B) NOTICE.--IF THE ARTICLE EXPIRES UNDER SUBSECTION (A)(2),
AS DETERMINED BY THE DEPARTMENT, THE DEPARTMENT SHALL TRANSMIT
NOTICE TO THE LEGISLATIVE REFERENCE BUREAU FOR PUBLICATION IN
THE PENNSYLVANIA BULLETIN.
Section 2. Section 704.3(a) of the act, added July 9, 2013
(P.L.369, No.55), is amended to read:
SECTION 8. SECTIONS 704.1(G) AND (G.2) AND 704.3(A) OF THE
ACT, AMENDED OR ADDED JULY 9, 2013 (P.L.369, NO.55), ARE AMENDED
TO READ:
SECTION 704.1. PAYMENTS TO COUNTIES FOR SERVICES TO
CHILDREN.--* * *
(G) [THE] EXCEPT AS PROVIDED UNDER AN EXECUTIVE APPROVAL OR
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AN APPROPRIATION UNDER THE ACT OF APRIL 9, 1929 (P.L.343,
NO.176), KNOWN AS "THE FISCAL CODE," THE DEPARTMENT SHALL
PROCESS PAYMENTS TO EACH COUNTY PURSUANT TO THIS ARTICLE FROM
FUNDS APPROPRIATED BY THE GENERAL ASSEMBLY [FOR EACH FISCAL
YEAR], WITHIN FIFTEEN DAYS OF PASSAGE OF THE GENERAL
APPROPRIATION BILL OR BY A DATE SPECIFIED UNDER PARAGRAPH (1),
(2), (3), (4) OR (5), WHICHEVER IS LATER. THE DEPARTMENT SHALL
PROCESS THE FOLLOWING APPLICABLE PAYMENTS TO THE COUNTY:
(1) BY JULY 15, TWENTY-FIVE PERCENT OF THE AMOUNT OF STATE
FUNDS ALLOCATED TO THE COUNTY UNDER SECTION 709.3.
(2) BY AUGUST 31, OR UPON APPROVAL BY THE DEPARTMENT OF THE
COUNTY'S FINAL CUMULATIVE REPORT FOR ITS EXPENDITURES FOR THE
PRIOR FISCAL YEAR, WHICHEVER IS LATER, TWENTY-FIVE PERCENT OF
THE AMOUNT OF STATE FUNDS ALLOCATED TO THE COUNTY UNDER SECTION
709.3, REDUCED BY THE AMOUNT OF AGGREGATE UNSPENT STATE FUNDS
PROVIDED TO THE COUNTY DURING THE PREVIOUS FISCAL YEAR.
(3) BY NOVEMBER 30, OR UPON APPROVAL BY THE DEPARTMENT OF
THE COUNTY'S REPORT FOR ITS EXPENDITURES FOR THE FIRST QUARTER
OF THE FISCAL YEAR, WHICHEVER IS LATER, TWENTY-FIVE PERCENT OF
THE AMOUNT OF STATE FUNDS ALLOCATED TO THE COUNTY UNDER SECTION
709.3, REDUCED BY THE AMOUNT OF UNSPENT STATE FUNDS ALREADY
PROVIDED TO THE COUNTY FOR THE FIRST QUARTER OF THE FISCAL YEAR.
(4) BY FEBRUARY 28, OR UPON APPROVAL BY THE DEPARTMENT OF
THE COUNTY'S REPORT FOR ITS EXPENDITURES FOR THE SECOND QUARTER
OF THE FISCAL YEAR, WHICHEVER IS LATER, TWELVE AND ONE-HALF
PERCENT OF THE AMOUNT OF STATE FUNDS ALLOCATED TO THE COUNTY
UNDER SECTION 709.3, ADJUSTED BY THE AMOUNT OF OVERSPENDING OR
UNDERSPENDING OF STATE FUNDS IN THE PREVIOUS QUARTERS, BUT NOT
TO EXCEED EIGHTY-SEVEN AND ONE-HALF PERCENT OF THE COUNTY'S
APPROVED STATE ALLOCATION.
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(5) UPON APPROVAL BY THE DEPARTMENT OF THE COUNTY'S FINAL
CUMULATIVE REPORT FOR ITS EXPENDITURES FOR THE FISCAL YEAR,
TWELVE AND ONE-HALF PERCENT OF THE AMOUNT OF STATE FUNDS
ALLOCATED TO THE COUNTY UNDER SECTION 709.3, ADJUSTED BY THE
AMOUNT OF OVERSPENDING OR UNDERSPENDING OF STATE FUNDS IN THE
PREVIOUS QUARTERS.
* * *
(G.2) SERVICE CONTRACTS OR AGREEMENTS SHALL INCLUDE A TIMELY
PAYMENT PROVISION THAT REQUIRES COUNTIES TO MAKE PAYMENT TO
SERVICE PROVIDERS WITHIN THIRTY DAYS OF THE COUNTY'S RECEIPT OF
AN INVOICE UNDER BOTH OF THE FOLLOWING CONDITIONS:
(1) THE INVOICE SATISFIES THE COUNTY'S REQUIREMENTS FOR A
COMPLETE AND ACCURATE INVOICE.
(2) FUNDS HAVE BEEN APPROPRIATED TO THE DEPARTMENT OR
APPROVED BY THE GOVERNOR FOR PAYMENTS TO COUNTIES UNDER
SUBSECTION (G).
* * *
Section 704.3. Provider Submissions.--(a) For fiscal [year]
years 2013-2014, 2014-2015 and 2015-2016, a provider shall
submit documentation of its costs of providing services; and the
department shall use such documentation, to the extent
necessary, to support the department's claim for Federal funding
and for State reimbursement for allowable direct and indirect
costs incurred in the provision of out-of-home placement
services.
* * *
SECTION 9. SECTION 709.3 OF THE ACT, ADDED AUGUST 5, 1991
(P.L.315, NO.30), IS AMENDED TO READ:
SECTION 709.3. LIMITS ON REIMBURSEMENTS TO COUNTIES.--(A)
REIMBURSEMENT FOR CHILD WELFARE SERVICES [MADE] BY THE
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DEPARTMENT TO COUNTIES DURING A FISCAL YEAR PURSUANT TO SECTION
704.1 SHALL NOT EXCEED THE FUNDS APPROPRIATED [EACH FISCAL
YEAR].
(A.1) REIMBURSEMENT FOR CHILD WELFARE SERVICES PROVIDED IN A
FISCAL YEAR SHALL BE APPROPRIATED OVER TWO FISCAL YEARS.
(B) THE ALLOCATION FOR EACH COUNTY PURSUANT TO SECTION
704.1(A) SHALL BE CALCULATED BY MULTIPLYING THE SUM OF THE
SOCIAL SECURITY ACT (PUBLIC LAW 74-271, 42 U.S.C. § 301 ET SEQ.)
TITLE IV-B FUNDS AND STATE FUNDS APPROPRIATED TO REIMBURSE
COUNTIES PURSUANT TO SECTION 704.1(A) BY A FRACTION, THE
NUMERATOR OF WHICH IS THE AMOUNT DETERMINED FOR THAT COUNTY'S
CHILD WELFARE NEEDS-BASED BUDGET AND THE DENOMINATOR IS THE
AGGREGATE CHILD WELFARE NEEDS-BASED BUDGET.
(C) IF THE SUM OF THE AMOUNTS APPROPRIATED FOR REIMBURSEMENT
UNDER [SECTION 704.1(A)] SUBSECTION (A) DURING THE FISCAL YEAR
IS NOT AT LEAST EQUIVALENT TO THE AGGREGATE CHILD WELFARE NEEDS-
BASED BUDGET FOR THAT FISCAL YEAR:
(1) EACH COUNTY SHALL BE PROVIDED A PROPORTIONATE SHARE
ALLOCATION OF THAT APPROPRIATION CALCULATED BY MULTIPLYING THE
SUM OF THE AMOUNTS APPROPRIATED FOR REIMBURSEMENT UNDER [SECTION
704.1(A)] SUBSECTION (A) BY A FRACTION, THE NUMERATOR OF WHICH
IS THE AMOUNT DETERMINED FOR THAT COUNTY'S CHILD WELFARE NEEDS-
BASED BUDGET AND THE DENOMINATOR IS THE AGGREGATE CHILD WELFARE
NEEDS-BASED BUDGET.
(2) NOTWITHSTANDING SUBSECTION (A), A COUNTY SHALL BE
ALLOWED REIMBURSEMENT BEYOND ITS PROPORTIONATE SHARE ALLOCATION
FOR THAT FISCAL YEAR FOR EXPENDITURES MADE IN ACCORDANCE WITH AN
APPROVED PLAN AND NEEDS-BASED BUDGET, BUT NOT ABOVE THAT AMOUNT
DETERMINED TO BE ITS NEEDS-BASED BUDGET.
(C.1) THE DEPARTMENT SHALL REIMBURSE COUNTIES WITH FUNDS
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APPROPRIATED IN THE FISCAL YEAR IN WHICH THE DEPARTMENT MAKES
THE REIMBURSEMENT PAYMENT FOR CHILD WELFARE SERVICES. THE
AGGREGATE REIMBURSEMENT FOR CHILD WELFARE SERVICES PROVIDED
DURING A FISCAL YEAR SHALL NOT EXCEED THE AMOUNT SPECIFIED AS
THE AGGREGATE CHILD WELFARE NEEDS-BASED BUDGET ALLOCATION BY THE
GENERAL ASSEMBLY AS NECESSARY TO FUND CHILD WELFARE SERVICES IN
THE GENERAL APPROPRIATION ACT FOR THAT FISCAL YEAR.
(D) FOR THE PURPOSE OF THIS SECTION, AN APPROPRIATION SHALL
BE CONSIDERED EQUIVALENT TO THE AGGREGATE CHILD WELFARE NEEDS IF
IT IS EQUIVALENT TO THE RESULT OBTAINED BY CALCULATING THE
AGGREGATE CHILD WELFARE NEEDS MINUS THE COUNTY SHARE OF YOUTH
DEVELOPMENT CENTER COSTS AND MINUS THE SOCIAL SECURITY ACT TITLE
IV-B FUNDING, PROVIDED, HOWEVER, AN APPROPRIATION SHALL BE
DEEMED EQUIVALENT IF IT IS EQUAL TO EIGHTY-TWO PERCENT OF THE
RESULT IN 1991-1992, NINETY PERCENT OF THE RESULT IN 1992-1993
AND NINETY-FIVE PERCENT OF THE RESULT IN 1993-1994.
(E) THE DEPARTMENT SHALL, BY REGULATION, DEFINE ALLOWABLE
COSTS FOR AUTHORIZED CHILD WELFARE SERVICES, PROVIDED THAT NO
REGULATION RELATING TO ALLOWABLE COSTS SHALL BE ADOPTED AS AN
EMERGENCY REGULATION PURSUANT TO SECTION 6(B) OF THE ACT OF JUNE
25, 1982 (P.L.633, NO.181), KNOWN AS THE "REGULATORY REVIEW
ACT."
SECTION 10. ARTICLE VIII-F OF THE ACT IS REPEALED:
[ARTICLE VIII-F
MEDICAID MANAGED CARE ORGANIZATION ASSESSMENTS
SECTION 801-F. DEFINITIONS.
THE FOLLOWING WORDS AND PHRASES WHEN USED IN THIS ARTICLE
SHALL HAVE THE MEANINGS GIVEN TO THEM IN THIS SECTION UNLESS THE
CONTEXT CLEARLY INDICATES OTHERWISE:
"ASSESSMENT PERCENTAGE." THE RATE ASSESSED PURSUANT TO THIS
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ARTICLE ON EVERY MEDICAID MANAGED CARE ORGANIZATION.
"ASSESSMENT PERIOD." THE TIME PERIOD IDENTIFIED IN THE
CONTRACT.
"ASSESSMENT PROCEEDS." THE STATE REVENUE COLLECTED FROM THE
ASSESSMENT PROVIDED FOR IN THIS ARTICLE, ANY FEDERAL FUNDS
RECEIVED BY THE COMMONWEALTH AS A DIRECT RESULT OF THE
ASSESSMENT AND ANY PENALTIES AND INTEREST RECEIVED UNDER SECTION
810-F.
"CONTRACT." THE AGREEMENT BETWEEN A MEDICAID MANAGED CARE
ORGANIZATION AND THE DEPARTMENT OF PUBLIC WELFARE.
"COUNTY MEDICAID MANAGED CARE ORGANIZATION." A COUNTY, OR AN
ENTITY ORGANIZED AND CONTROLLED DIRECTLY OR INDIRECTLY BY A
COUNTY OR A CITY OF THE FIRST CLASS, THAT IS A PARTY TO A
MEDICAID MANAGED CARE CONTRACT WITH THE DEPARTMENT OF PUBLIC
WELFARE.
"DEPARTMENT." THE DEPARTMENT OF PUBLIC WELFARE OF THE
COMMONWEALTH.
"MEDICAID." THE PROGRAM ESTABLISHED UNDER TITLE XIX OF THE
SOCIAL SECURITY ACT (49 STAT. 620, 42 U.S.C. § 1396 ET SEQ.).
"MEDICAID MANAGED CARE ORGANIZATION." A MEDICAID MANAGED
CARE ORGANIZATION AS DEFINED IN SECTION 1903(M)(1)(A) OF THE
SOCIAL SECURITY ACT (49 STAT. 620, 42 U.S.C. § 1396B(M)(1)(A))
THAT IS A PARTY TO A MEDICAID MANAGED CARE CONTRACT WITH THE
DEPARTMENT OF PUBLIC WELFARE. THE TERM SHALL INCLUDE A COUNTY
MEDICAID MANAGED CARE ORGANIZATION AND A PERMITTED ASSIGNEE OF A
MEDICAID MANAGED CARE CONTRACT BUT SHALL NOT INCLUDE AN ASSIGNOR
OF A MEDICAID MANAGED CARE CONTRACT.
"SECRETARY." THE SECRETARY OF PUBLIC WELFARE OF THE
COMMONWEALTH.
"SOCIAL SECURITY ACT." 49 STAT. 620, 42 U.S.C. § 301 ET SEQ.
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SECTION 802-F. AUTHORIZATION.
THE DEPARTMENT SHALL IMPLEMENT AN ASSESSMENT ON EACH MEDICAID
MANAGED CARE ORGANIZATION, SUBJECT TO THE CONDITIONS AND
REQUIREMENTS SPECIFIED IN THIS ARTICLE.
SECTION 803-F. IMPLEMENTATION.
THE ASSESSMENT SHALL BE IMPLEMENTED ON AN ANNUAL BASIS,
THROUGH PERIODIC SUBMISSIONS NOT TO EXCEED FIVE TIMES PER YEAR
BY MEDICAID MANAGED CARE ORGANIZATIONS, AS A HEALTH CARE-RELATED
FEE AS DEFINED IN SECTION 1903(W)(3)(B) OF THE SOCIAL SECURITY
ACT, OR ANY AMENDMENTS THERETO, AND MAY BE IMPOSED AND IS
REQUIRED TO BE PAID ONLY TO THE EXTENT THAT THE REVENUES
GENERATED FROM THE ASSESSMENT QUALIFY AS THE STATE SHARE OF
PROGRAM EXPENDITURES ELIGIBLE FOR FEDERAL FINANCIAL
PARTICIPATION.
SECTION 804-F. ASSESSMENT PERCENTAGE.
(A) AMOUNT.--THE ASSESSMENT PERCENTAGE SHALL BE UNIFORM FOR
ALL MEDICAID MANAGED CARE ORGANIZATIONS, DETERMINED IN
ACCORDANCE WITH THIS SECTION AND IMPLEMENTED BY THE DEPARTMENT
AS APPROVED BY THE GOVERNOR AFTER NOTIFICATION TO AND IN
CONSULTATION WITH THE MEDICAID MANAGED CARE ORGANIZATIONS. THE
ASSESSMENT PERCENTAGE SHALL BE SUBJECT TO THE MAXIMUM AGGREGATE
AMOUNT THAT MAY BE ASSESSED PURSUANT TO 42 CFR 433.68(F)(3)(I)
(RELATING TO PERMISSIBLE HEALTH CARE-RELATED TAXES) OR ANY
SUBSEQUENT MAXIMUM ESTABLISHED BY FEDERAL LAW.
(B) NOTICE.--SUBJECT TO THE PROVISIONS OF SUBSECTION (C),
THE DEPARTMENT SHALL NOTIFY EACH MEDICAID MANAGED CARE
ORGANIZATION OF A PROPOSED ASSESSMENT PERCENTAGE. MEDICAID
MANAGED CARE ORGANIZATIONS SHALL HAVE 30 DAYS FROM THE DATE OF
THE PROPOSED ASSESSMENT PERCENTAGE NOTICE TO PROVIDE WRITTEN
COMMENTS TO THE DEPARTMENT REGARDING THE PROPOSED ASSESSMENT.
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UPON EXPIRATION OF THE 30-DAY COMMENT PERIOD, THE DEPARTMENT,
AFTER CONSIDERATION OF THE COMMENTS, SHALL PROVIDE EACH MEDICAID
MANAGED CARE ORGANIZATION WITH A SECOND NOTICE ANNOUNCING THE
ASSESSMENT PERCENTAGE. ONCE EFFECTIVE, AN ASSESSMENT PERCENTAGE
WILL REMAIN IN EFFECT UNTIL THE DEPARTMENT NOTIFIES EACH
MEDICAID MANAGED CARE ORGANIZATION OF A NEW ASSESSMENT
PERCENTAGE IN ACCORDANCE WITH THE NOTICE PROVISIONS CONTAINED IN
THIS SECTION.
(C) INITIAL ASSESSMENT.--THE INITIAL ASSESSMENT PERCENTAGE
MAY BE IMPOSED RETROACTIVELY TO THE BEGINNING OF AN ASSESSMENT
PERIOD BEGINNING ON OR AFTER JULY 1, 2004. ONCE EFFECTIVE, THE
INITIAL ASSESSMENT PERCENTAGE WILL REMAIN IN EFFECT UNTIL THE
DEPARTMENT NOTIFIES EACH MEDICAID MANAGED CARE ORGANIZATION OF A
NEW ASSESSMENT PERCENTAGE IN ACCORDANCE WITH THE NOTICE
PROVISIONS CONTAINED IN THIS SECTION.
SECTION 805-F. CALCULATION AND PAYMENT.
USING THE ASSESSMENT PERCENTAGE ESTABLISHED UNDER SECTION
804-F, EACH MEDICAID MANAGED CARE ORGANIZATION SHALL CALCULATE
THE ASSESSMENT AMOUNT FOR EACH ASSESSMENT PERIOD ON A REPORT
FORM SPECIFIED BY THE CONTRACT AND SHALL SUBMIT THE COMPLETED
REPORT FORM AND TOTAL AMOUNT OWED TO THE DEPARTMENT ON A DUE
DATE SPECIFIED BY THE CONTRACT. THE MEDICAID MANAGED CARE
ORGANIZATION SHALL REPORT NET OPERATING REVENUE FOR PURPOSES OF
THE ASSESSMENT CALCULATION AS SPECIFIED IN THE CONTRACT.
SECTION 806-F. USE OF ASSESSMENT PROCEEDS.
NO MEDICAID MANAGED CARE ORGANIZATION SHALL BE GUARANTEED A
REPAYMENT OF ITS ASSESSMENT IN DEROGATION OF 42 CFR 433.68(F)
(RELATING TO PERMISSIBLE HEALTH CARE-RELATED TAXES), PROVIDED,
HOWEVER, IN EACH FISCAL YEAR IN WHICH AN ASSESSMENT IS
IMPLEMENTED, THE DEPARTMENT SHALL USE THE ASSESSMENT PROCEEDS TO
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MAINTAIN ACTUARIALLY SOUND RATES AS DEFINED IN THE CONTRACT FOR
THE MEDICAID MANAGED CARE ORGANIZATIONS TO THE EXTENT
PERMISSIBLE UNDER FEDERAL AND STATE LAW OR REGULATION AND
WITHOUT CREATING A GUARANTEE TO HOLD HARMLESS, AS THOSE TERMS
ARE USED IN 42 CFR 433.68(F).
SECTION 807-F. RECORDS.
UPON WRITTEN REQUEST BY THE DEPARTMENT, A MEDICAID MANAGED
CARE ORGANIZATION SHALL FURNISH TO THE DEPARTMENT SUCH RECORDS
AS THE DEPARTMENT MAY SPECIFY IN ORD